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

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ClinicalTrials.gov Identifier: NCT01262053
Recruitment Status : Unknown
Verified December 2010 by Montefiore Medical Center.
Recruitment status was:  Active, not recruiting
First Posted : December 17, 2010
Last Update Posted : December 27, 2010
Sponsor:
Information provided by:

Study Description
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.


Condition or disease Intervention/treatment
Wrong Patient Computerized Physician Order Entry Errors Other: Passive Intervention Other: Active Intervention Other: Control

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.

Study Design

Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 5000 participants
Allocation: Randomized
Intervention Model: Factorial Assignment
Masking: Single (Investigator)
Official Title: Investigating Wrong-Patient CPOE Errors
Study Start Date : December 2010
Estimated Primary Completion Date : May 2011
Estimated Study Completion Date : May 2011
Arms and Interventions

Arm Intervention/treatment
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


Outcome Measures

Primary Outcome Measures :
  1. Reduction of wrong patient CPOE errors [ Time Frame: Within one hour of placing an order ]
    Compare reduction of wrong patient CPOE errors in each intervention group against a control


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


Eligibility Criteria

Information from the National Library of Medicine

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Ages Eligible for Study:   Child, Adult, Senior
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

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

Exclusion Criteria:

Contacts and Locations

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): 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