Association of Display of Patient Photographs in the Electronic Health Record With Wrong-Patient Order Entry Errors | Electronic Health Records | JAMA Network Open | JAMA Network
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    1 Comment for this article
    Overstated number of orders?
    David Polaner, MD, FAAP | Seattle Children's Hospital and University of Washington School of Medicine
    One of the usual ways of increasing efficiency and decreasing the likelihood of missing orders in all EHR systems is that orders can be grouped into order sets, in which multiple orders are accumulated into a single purpose specific order set (e.g., admission orders, sepsis work-up orders, etc.). These order sets commonly comprise 10 or more individual orders across multiple categories. While the individual items in the order set might require selection or clarification, the order set itself is called up with a single click.

    In this study the unit of analysis was one order. If the primary analysis
    de-aggregates orders in order sets, it would overestimate the number of WPOE errors- the physician in reality made a single error in pulling up the order set for the wrong patient even though the number of orders in that order set is greater than one. This methodology thereby inflates both the "n" of orders and the number of WPOE orders (assuming all of the orders in the set are tagged as WPOE) in the analysis. Because the number of individual orders in a set varies, the variability of how this affects the data is unknown. It appears that the authors have tried to mitigate this limitation in their secondary analysis by looking at order sessions, but it is still not clear if these sessions comprised individual orders, order sets, or a mixture of the two.
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    Original Investigation
    Emergency Medicine
    November 11, 2020

    Association of Display of Patient Photographs in the Electronic Health Record With Wrong-Patient Order Entry Errors

    Author Affiliations
    • 1Department of Quality and Safety, Brigham and Women’s Hospital, Boston, Massachusetts
    • 2Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
    • 3Harvard T.H. Chan School of Public Health, Boston, Massachusetts
    • 4Vanderbilt University Medical Center, Nashville, Tennessee
    • 5Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
    • 6Department of Emergency Medicine, Rhode Island Hospital, Providence
    • 7Alpert Medical School of Brown University, Providence, Rhode Island
    • 8Department of Quality and Safety, NewYork-Presbyterian Hospital, New York, New York
    JAMA Netw Open. 2020;3(11):e2019652. doi:10.1001/jamanetworkopen.2020.19652
    Key Points

    Question  Can wrong-patient order entry errors be reduced with noninterruptive display of patient photographs?

    Findings  In this cohort study involving 2 558 746 orders that were placed for 71 851 patients, displaying a patient’s photograph in the banner of the electronic health record was associated with a significant reduction in the rate of wrong-patient order entry errors. Unlike prior interventions, this solution required no added practitioner time burden or risk of alert fatigue.

    Meaning  The results of this study suggest that capturing patient photographs and displaying them in the electronic health record may be a simple and cost-effective strategy for reducing wrong-patient errors.


    Importance  Wrong-patient order entry (WPOE) errors have a high potential for harm; these errors are particularly frequent wherever workflows are complex and multitasking and interruptions are common, such as in the emergency department (ED). Previous research shows that interruptive solutions, such as electronic patient verification forms or alerts, can reduce these types of errors but may be time-consuming and cause alert fatigue.

    Objective  To evaluate whether the use of noninterruptive display of patient photographs in the banner of the electronic health record (EHR) is associated with a decreased rate of WPOE errors.

    Design, Setting, and Participants  In this cohort study, data collected as part of care for patients visiting the ED of a large tertiary academic urban hospital in Boston, Massachusetts, between July 1, 2017, and June 31, 2019, were analyzed.

    Exposures  In a quality improvement initiative, the ED staff encouraged patients to have their photographs taken by informing them of the intended safety impact.

    Main Outcomes and Measures  The rate of WPOE errors (measured using the retract-and-reorder method) for orders placed when the patient’s photograph was displayed in the banner of the EHR vs the rate for patients without a photograph displayed. The primary analysis focused on orders placed in the ED; a secondary analysis included orders placed in any care setting.

    Results  A total of 2 558 746 orders were placed for 71 851 unique patients (mean [SD] age, 49.2 [19.1] years; 42 677 (59.4%) female; 55 109 (76.7%) non-Hispanic). The risk of WPOE errors was significantly lower when the patient’s photograph was displayed in the EHR (odds ratio, 0.72; 95% CI, 0.57-0.89). After this risk was adjusted for potential confounders using multivariable logistic regression, the effect size remained essentially the same (odds ratio, 0.57; 95% CI, 0.52-0.61). Risk of error was significantly lower in patients with higher acuity levels and among patients whose race was documented as White.

    Conclusions and Relevance  This cohort study suggests that displaying patient photographs in the EHR provides decision support functionality for enhancing patient identification and reducing WPOE errors while being noninterruptive with minimal risk of alert fatigue. Successful implementation of such a program in an ED setting involves a modest financial investment and requires appropriate engagement of patients and staff.