Reducing Wrong-Patient Errors in the NICU through an Electronic Medical Record Identification Re-Entry Function

Sunday, October 12, 2014: 9:30 AM
Marina Ballroom Salon D (San Diego Marriott Marquis )
Jason Adelman, MD, MS1, Robert Angert, MD2, Clyde Schechter, MD3, Judy Aschner, MD2, Andrew Racine, MD1, Jeffrey Weiss, MD1, Amisha Rai1, Matthew Berger, MD1, Stan Reissman, MSW1, Bejoy Chacko1 and William Southern, MD1, (1)Montefiore Medical Center, Bronx, NY, (2)Pediatrics, Neonatology, Children's Hospital at Montefiore - Albert Einstein College of Medicine, Bronx, NY, (3)Albert Einstein College of Medicine, Bronx, NY

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.