Overview

This trial is active, not recruiting.

Condition wrong patient computerized physician order entry errors
Treatments passive intervention, active intervention, control
Sponsor Montefiore Medical Center
Start date December 2010
End date May 2011
Trial size 5000 participants
Trial identifier NCT01262053, 10-05-156E

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.

United States No locations recruiting
Other Countries No locations recruiting

Study Design

Allocation randomized
Endpoint classification safety study
Intervention model factorial assignment
Masking single blind (investigator)
Arm
(Experimental)
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.
passive intervention
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).
(Experimental)
The user will be required to enter the initials, age and sex of the activated patient prior to placing any orders.
active intervention
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.
(Active Comparator)
Parallel control with no intervention
control
Parallel control with no intervention

Primary Outcomes

Measure
Reduction of wrong patient CPOE errors
time frame: Within one hour of placing an order

Secondary Outcomes

Measure
Impact of interventions on workflow
time frame: Within one hour of placing an order

Eligibility Criteria

Male or female participants of any age.

Inclusion Criteria: - All providers that place order in the Computerized Physician Order Entry (CPOE) System Exclusion Criteria: - none

Additional Information

Official title Investigating Wrong-Patient CPOE Errors
Principal investigator Jason S Adelman, MD, MS
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.
Trial information was received from ClinicalTrials.gov and was last updated in December 2010.
Information provided to ClinicalTrials.gov by Montefiore Medical Center.