Healthcare News & Insights

Study: Doctors make CPOE errors with 1 in 37 patients

Health IT can help healthcare providers avoid errors that may threaten patient safety – but they won’t eliminate mistakes completely, warns a new study. 

One health IT area where serious errors can occur is the orders made through a computerized physician order entry (CPOE) system, according to a recent study published in the Journal of the American Medical Informatics Association. One common mistake is when doctors place orders for the wrong patient.

The goal of the study, conducted by researchers at Montefiore Medical Center in New York, was to find a way to detect wrong-patient orders made in hospitals’ CPOE system — and to correct and prevent those errors before they put patient safety at risk.

The researchers used data from 2009 to look for incidents in which doctors retracted an order within 10 minutes of placing it and then placed a new order 10 minutes later.

After looking at the data for 9 million patients treated at Montefiore’s four hospitals that year, researchers found 6,885 incidents when a doctor retracted an order and placed a new one. Based on interviews with doctors, they estimated that in 76% of those cases, or approximately 5,246 incidents, the doctor placed an order for the wrong patient and then caught the error.

Fortunately, researchers noted that very few of those near misses posed serious threats to patient safety. However, the number of mistakes shows how easy it can be for something to go wrong. One-sixth of all physicians at Montefiore had made a wrong-patient order, according to the researchers’ analysis, and an incorrect order was placed for one in 37 patients admitted to the hospitals.

Of course, those are the errors that were caught and immediately corrected — the study doesn’t reveal how many orders placed for the wrong patients actually went through.

How can providers and software vendors prevent those potentially dangerous errors? One study conducted at Children’s Hospital Colorado found that including a patient’s photo in an order verification prompt can greatly reduce the chance of an order being placed for the wrong person.

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