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

The recruitment status of this study is unknown because the information has not been verified recently.
Verified December 2010 by Montefiore Medical Center.
Recruitment status was  Active, not recruiting
Sponsor:
Information provided by:
Montefiore Medical Center
ClinicalTrials.gov Identifier:
NCT01262053
First received: December 15, 2010
Last updated: December 24, 2010
Last verified: December 2010
  Purpose

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.


Condition Intervention
Wrong Patient Computerized Physician Order Entry Errors
Other: Passive Intervention
Other: Active Intervention
Other: Control

Study Type: Interventional
Study Design: Allocation: Randomized
Endpoint Classification: Safety Study
Intervention Model: Factorial Assignment
Masking: Single Blind (Investigator)
Official Title: Investigating Wrong-Patient CPOE Errors

Further study details as provided by Montefiore Medical Center:

Primary Outcome Measures:
  • Reduction of wrong patient CPOE errors [ Time Frame: Within one hour of placing an order ] [ Designated as safety issue: Yes ]
    Compare reduction of wrong patient CPOE errors in each intervention group against a control


Secondary Outcome Measures:
  • Impact of interventions on workflow [ Time Frame: Within one hour of placing an order ] [ Designated as safety issue: Yes ]
    Compare the efficacy and workflow impact of two distinct interventions to prevent wrong-patient near miss CPOE errors against a control


Estimated Enrollment: 5000
Study Start Date: December 2010
Estimated Study Completion Date: May 2011
Estimated Primary Completion Date: May 2011 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
Experimental: 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.
Other: 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: Invasive Intervention
The user will be required to enter the initials, age and sex of the activated patient prior to placing any orders.
Other: 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: Control
Parallel control with no intervention
Other: Control
Parallel control with no intervention

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

Genders Eligible for Study:   Both
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

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

Exclusion Criteria:

  • none
  Contacts and Locations
Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below. For general information, see Learn About Clinical Studies.

Please refer to this study by its ClinicalTrials.gov identifier: NCT01262053

Locations
United States, New York
Montefiore Medical Center
Bronx, New York, United States, 10467
Sponsors and Collaborators
Montefiore Medical Center
Investigators
Principal Investigator: Jason S Adelman, MD, MS Montefiore Medical Center
  More Information

Publications:
Responsible Party: Jason Adelman, MD, MS/Patient Safety Officer, Montefiore Medical Center
ClinicalTrials.gov Identifier: NCT01262053     History of Changes
Other Study ID Numbers: 10-05-156E
Study First Received: December 15, 2010
Last Updated: December 24, 2010
Health Authority: United States: Institutional Review Board
United States: Federal Government

Keywords provided by Montefiore Medical Center:
Computerized Physician Order Entry
CPOE
Wrong Patient
Juxtaposition
Patient Safety
Medical Errors

ClinicalTrials.gov processed this record on October 29, 2014