Clinical trial NCT01262053: Investigating Wrong-Patient Computerized Physician Order Entry (CPOE) Errors
Official title: Investigating Wrong-Patient CPOE Errors
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: Wrong Patient Computerized Physician Order Entry Errors
Keywords: Computerized Physician Order Entry
CPOE
Wrong Patient
Juxtaposition
Patient Safety
Medical Errors
Lead sponsor: Montefiore Medical Center
Sponsor class: OTHER
First posted: 2010-12-17
Enrollment: 4028
Sex: ALL
Standard ages: CHILD
ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: FACTORIAL
Primary purpose: OTHER

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.

Eligibility criteria: Inclusion Criteria:

* All providers that place order in the Computerized Physician Order Entry (CPOE) System

Exclusion Criteria:

* none

Primary outcomes:
measure: Reduction of wrong patient CPOE errors
timeFrame: Within one hour of placing an order
Secondary outcomes:
measure: Impact of interventions on workflow
timeFrame: Within one hour of placing an order
Other outcomes:
Locations:
city: Bronx
country: United States
facility: Montefiore Medical Center
state: New York
Study officials:
affiliation: Montefiore Medical Center
name: Jason S Adelman, MD, MS
role: PRINCIPAL_INVESTIGATOR
References:
citation: Ash JS, Sittig DF, Poon EG, Guappone K, Campbell E, Dykstra RH. The extent and importance of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2007 Jul-Aug;14(4):415-23. doi: 10.1197/jamia.M2373. Epub 2007 Apr 25.
citation: Koppel R, Metlay JP, Cohen A, Abaluck B, Localio AR, Kimmel SE, Strom BL. Role of computerized physician order entry systems in facilitating medication errors. JAMA. 2005 Mar 9;293(10):1197-203. doi: 10.1001/jama.293.10.1197.
citation: Weiner JP, Kfuri T, Chan K, Fowles JB. "e-Iatrogenesis": the most critical unintended consequence of CPOE and other HIT. J Am Med Inform Assoc. 2007 May-Jun;14(3):387-8; discussion 389. doi: 10.1197/jamia.M2338. Epub 2007 Feb 28. No abstract available.
citation: Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2006 Sep-Oct;13(5):547-56. doi: 10.1197/jamia.M2042. Epub 2006 Jun 23.
citation: Wachter RM. Expected and unanticipated consequences of the quality and information technology revolutions. JAMA. 2006 Jun 21;295(23):2780-3. doi: 10.1001/jama.295.23.2780. No abstract available.