Two Interventions to Reduce Wrong-Patient CPOE Orders

July 13, 2012 | Strategic Insights for Ambulatory Care


Two interventions that prompt physicians to either verify or re-enter patient identification information led to substantial reductions in wrong-patient errors in a computerized provider order-entry (CPOE) system, according to a study published online June 29, 2012, by the Journal of the American Medical Informatics Association. The authors used a “retract-and-reorder” tool to estimate the rate of wrong-patient orders in four hospitals during 2009. The tool flagged orders that were entered, retracted within 10 minutes, and then reordered by the same provider for another patient within 10 minutes of retraction; they estimate 5,246 such orders were entered during the pre-intervention period. During the intervention period, comprising 3,281,544 electronic orders from 4,028 providers in the same four hospitals, two interventions were tested.

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