Investigating Wrong-Patient Computerized Physician Order Entry (CPOE) Errors
- Conditions
- Wrong Patient Computerized Physician Order Entry Errors
- Interventions
- Other: Active InterventionOther: Passive InterventionOther: Control
- Registration Number
- NCT01262053
- Lead Sponsor
- Montefiore Medical Center
- Brief Summary
With the increased adoption of CPOE systems, it is important to recognize that design flaws have resulted in the creation of new types of iatrogenic medical errors. An example of a new type of iatrogenic medical error introduced by CPOE systems has been named "juxtaposition errors". Juxtaposition errors, as defined by Ash, et al. are "errors that can result when something is close to something else on the screen, and the wrong option is too easily clicked in error." Juxtaposition errors can lead to a patient receiving a medication, a test, or a treatment intended for another patient, sometimes with dire consequences. Juxtaposition errors are likely a subclass of a broader group of wrong-patient CPOE errors that have multiple etiologies.
The primary objectives of this research proposal is to investigate the prevalence of wrong-patient near miss CPOE errors, to investigate the root cause of these errors, and to investigate and compare the efficacy and workflow impact of two distinct interventions to prevent these errors.
- Detailed Description
Computerized Physician Order Entry (CPOE) systems have been shown to prevent medical errors, and have become a major component of the patient safety movement. To accelerate the adoption of clinical information technology including CPOE systems, the American Recovery and Reinvestment Act of 2009 allocated approximately $17 billion as incentive payments to providers and hospitals who implement health information technology. With the increased adoption of CPOE systems, however, it is important to recognize that design flaws have resulted in the creation of new types of iatrogenic medical errors. In addition, CPOE systems developed with suboptimal and onerous user interfaces have contributed to entire systems being rejected by physicians. The ideal CPOE system maximizes medical error reduction, minimizes medical error creation, and has a user friendly interface that is accepted by nurses, physicians, and pharmacists.
An example of a new type of iatrogenic medical error introduced by CPOE systems has been named "juxtaposition errors" . Juxtaposition errors, as defined by Ash, et al. are "errors that can result when something is close to something else on the screen, and the wrong option is too easily clicked in error." Juxtaposition errors can lead to a patient receiving a medication, a test, or a treatment intended for another patient, sometimes with dire consequences.
Juxtaposition errors are likely a subclass of a broader group of wrong-patient CPOE errors that have multiple etiologies. Other possible causes of wrong-patient CPOE orders include interruption errors, or double-interruption errors.
Primary Objectives:
* Specific Aim 1: Investigate the prevalence of wrong-patient near miss CPOE errors.
* Specific Aim 2: Investigate the root cause of wrong-patient near miss CPOE errors.
* Specific Aim 3: Investigate and compare the efficacy and workflow impact of two distinct interventions to prevent wrong-patient near miss CPOE errors against a control.
Recruitment & Eligibility
- Status
- COMPLETED
- Sex
- All
- Target Recruitment
- 4028
- All providers that place order in the Computerized Physician Order Entry (CPOE) System
- none
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- FACTORIAL
- Arm && Interventions
Group Intervention Description Active Intervention Active Intervention The user will be required to enter the initials, age and sex of the activated patient prior to placing any orders. Passive Intervention Passive Intervention When a user is about to place orders on a patient, a pop up alert will show the user the name, age, sex, room number and MR# of the patient who is currently activated. Control Control Parallel control with no intervention
- Primary Outcome Measures
Name Time Method Reduction of wrong patient CPOE errors Within one hour of placing an order Compare reduction of wrong patient CPOE errors in each intervention group against a control
- Secondary Outcome Measures
Name Time Method Impact of interventions on workflow Within one hour of placing an order Compare the efficacy and workflow impact of two distinct interventions to prevent wrong-patient near miss CPOE errors against a control
Trial Locations
- Locations (1)
Montefiore Medical Center
🇺🇸Bronx, New York, United States