AHRQ Funds Study on ‘Wrong Patient’ EHR Errors

Computerized provider order entry (CPOE) by licensed healthcare professionals for medication orders has been shown to improve patient safety, improve care quality and reduce medication errors.1 It is also a core requirement for demonstrating meaningful use of certified electronic health records (EHRs) to qualify for an incentive payment through the Medicare EHR Incentive Program administered by the Centers for Medicare & Medicaid Services (CMS).

But certain types of errors occur frequently in these systems, including entering orders on the wrong patient file.2 By one measure, approximately one in six providers placed at least one electronic order on the wrong patient, and approximately one in 37 patients admitted that the hospital had an order placed for them that was intended for another patient.2

In 2014, AHRQ provided $300,000 in grant funding to Albert Einstein College of Medicine of Yeshiva University, Montefiore Medical Center, and Brigham and Women’s Hospital, in the first study focused on the impact of multiple patient files open at the same time during CPOE. It would be a prospective, observational study examining the relationship between the number of records open at the time of placing an order and the risk of placing an order on the wrong patient.3

The study comes after concerns that high patient volume and provider unfamiliarity with EHR systems could cause patient data to be entered into the wrong file with potentially deadly consequences. If incorrect information that has been entered for a particular patient into the electronic record, it may lead to prescribing the wrong medication, unnecessary testing, or a provider basing a medical decision on the wrong patient’s information.

To determine the number of errors, researchers will compare the number of “wrong patient” entries in two different CPOE systems: systems that allow multiple patient files to be opened at the same time vs. systems that restrict the user to open only one file at a time. The AHRQ found that more than 80 percent of the chief information officers use CPOE systems that allow multiple patient files to be opened at the same time.4

A study from Office of the National Coordinator for Health Information Technology (ONC) reveals that approximately 15 percent of doctors contend that their EHR inadvertently led them to select the wrong medication or lab order from a list.5 This issue is exacerbated in clinical situations where there may be multiple providers caring for the same patient, particularly when multiple medications are involved.6

Use of EHR systems by office-based physicians increased from 18% in 2001 to 48% in 2009 and estimated to be about 78% in 2013.7 It has seen a dramatic increase since 2009 when HITECH Act authorized incentive payments to increase EHR adoption. Currently, at least 70,000 U.S. physicians use CPOE systems to place orders2 and this number is expected to rise in coming years as hospitals continue to take advantage of federal incentives.2

Technology’s impact on patient safety is a topic of interest throughout the healthcare technology industry and among regulators as healthcare professionals and hospitals seek to incorporate increasingly sophisticated information systems into their practices. EHRs have a great potential to increase patient care and safety, which is what research efforts, such as this study funded by AHRQ, hope to do. If the study shows that the CPOE systems that allow for multiple files to be opened simultaneously have an adverse effect on patient safety, technological adjustments may be needed.

Has your hospital or practice adopted an EHR system, or have you experienced a “wrong patient” error?