Investigating Wrong-Patient Computerized Physician Order Entry (CPOE) Errors

Study Overview
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Brief Summary
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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
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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.

Official Title
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Investigating Wrong-Patient CPOE Errors

Conditions
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Wrong Patient Computerized Physician Order Entry Errors

Intervention / Treatment
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* Other: Passive Intervention
* Other: Active Intervention
* Other: Control


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: All providers that place order in the Computerized Physician Order Entry (CPOE) System Exclusion Criteria: none
Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Other
Allocation: Randomized
Intervention Model: Factorial Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Passive Intervention<br>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. | Other: Passive Intervention<br>* 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. The point of the alert is to display identification information about the patient as a double check for the provider to make sure he is on the correct patient. This alert will only occur once at the onset of each order session (i.e. the provider will not be alerted for every single order, but if the provider leaves the order pad and then returns, the alert will reoccur).<br>|
| Experimental: Active Intervention<br>The user will be required to enter the initials, age and sex of the activated patient prior to placing any orders. | Other: Active Intervention<br>* The user will be required to enter the initials, age and sex of the activated patient prior to placing any orders. For example, for a patient named Donald Duck who is 76 years old and male, the user will be required to type dd76m to unlock the order pad. This step will NOT be required for every order, but WILL be required every time the user enters the order pad (i.e. if a user leaves the order pad and then returns, the system will require the initials, age and sex to be re-entered as above). This will be a forcing function.<br>|
| Active Comparator: Control<br>Parallel control with no intervention | Other: Control<br>* Parallel control with no intervention<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Reduction of wrong patient CPOE errors | Compare reduction of wrong patient CPOE errors in each intervention group against a control | Within one hour of placing an order | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Impact of interventions on workflow | Compare the efficacy and workflow impact of two distinct interventions to prevent wrong-patient near miss CPOE errors against a control | Within one hour of placing an order | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Computerized Physician Order Entry, CPOE, Wrong Patient, Juxtaposition, Patient Safety, Medical Errors