Reducing Wrong-Patient Errors in the NICU through an Electronic Medical Record Identification Re-Entry Function
Purpose: Wrong-patient errors are common in hospitalized patients when using computerized order entry (CPOE) systems. Re-verifying patient identification prior to placing orders has been demonstrated to reduce the rate of wrong-patient orders entered in a mixed-age hospital population. NICU patients are believed to be particularly susceptible to wrong-patient errors because in most institutions they are often given a non-distinct temporary fist name such as Babyboy or Babygirl. We assessed the effectiveness of adding an identification re-entry function to the CPOE system for preventing wrong-patient errors in the NICU, and evaluated the performance of this function in the NICU as compared to the rest of the medical center.
Methods: We conducted a before-after intervention study where an identification re-entry function was added to the CPOE system that required providers enter the patient's initials, age, and gender prior to beginning an order entry session for a patient. A cohort of orders entered prior to the change acted as the control for this study. A validated algorithm designed to measure near-miss wrong-patient errors called the Retract-and-Reorder tool (RAR) was developed at our institution. This algorithm identifies orders that are placed on one patient, retracted, and then ordered on another patient in a short period of time. Measurements were made in our CPOE system before and after the addition of the identification re-entry function. Wrong-patient orders were measured by order session, so that multiple orders placed for a single patient during a login by a single provider counted only once.
Results: During the pre-intervention period from 1/2007- 6/2010, there were 303 RAR order sessions identified among 122,000 order sessions (rate of 284/100,000 order sessions) in the NICU. In the post-intervention period, from 1/2012- 6/2013, there were 94 RAR order sessions identified among 76,639 (rate of 123/100,000 order sessions), which represents a 50.6% reduction. This was in contrast to the 17.8% reduction seen in non-neonates, whose RAR rate decreased from 178 RAR events/100,000 orders to 146 RAR events/100,000 orders.
Conclusion: Introducing an identification re-entry function was followed by a significant decrease in wrong-patient orders in the NICU, as measured by the RNR tool. The magnitude of error reduction in the NICU was considerably greater than the reduction in the non-neonate hospitalized population. In fact, the reduction in the NICU was so great that post-intervention the rate of wrong-patient errors was lower in the NICU population than in the non-neonate population. The marked effect the identification re-entry function had in the NICU is consistent with previous research that suggests the temporary, non-distinct, first names assigned to neonates increases the risk of wrong-patient errors.