Customize your JAMA Network experience by selecting one or more topics from the list below.
Identify all potential conflicts of interest that might be relevant to your comment.
Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.
Err on the side of full disclosure.
If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.
Not all submitted comments are published. Please see our commenting policy for details.
Salmasian H, Blanchfield BB, Joyce K, et al. Association of Display of Patient Photographs in the Electronic Health Record With Wrong-Patient Order Entry Errors. JAMA Netw Open. 2020;3(11):e2019652. doi:10.1001/jamanetworkopen.2020.19652
Can wrong-patient order entry errors be reduced with noninterruptive display of patient photographs?
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.
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.
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.
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.
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.
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.
Create a personal account or sign in to: