Jason Adelman, MD, MS
Dr. Adelman’s Patient Safety Research Program began with the development of the Wrong-Patient Retract-and-Reorder (RAR) Measure—a valid and reliable method of quantifying the frequency of wrong-patient orders placed in electronic ordering systems. The Wrong-Patient RAR measure was the first automated measure of medical errors and the first Health IT Safety Measure endorsed by the National Quality Forum. The RAR method identifies thousands of near-miss, wrong-patient errors per year in large health systems, enabling researchers to test interventions to prevent this type of error.
The Wrong-Patient RAR measure has been used to evaluate the effectiveness of patient safety interventions in several studies conducted in different electronic health record systems and clinical settings, including in the neonatal intensive care unit (NICU). The measure is the primary outcome measure for three federally funded studies supported by the Agency for Healthcare Research and Quality (R21HS023704, R01HS024945) and the National Institute for Child Health and Human Development (R01HD094793). Additional research is underway to extend the RAR methodology to other types of errors, such as wrong-drug errors, and develop new health IT safety measures (R01HS024538).
Results of Dr. Adelman’s research led to national patient safety guidance, including a recommendation issued by the Office of the National Coordinator for Health Information Technology that healthcare organizations use the Wrong-Patient RAR measure to monitor the frequency of wrong-patient orders. Effective 2019, The Joint Commission will require that hospitals adopt a distinct newborn naming convention that incorporates the mother’s first name, based on studies by Adelman and colleagues.
- Developing and Validating Health IT Safety Measures to Capture Violations of the Five Rights of Medication Safety (AHRQ R01). Study Period: 9/1/2016–6/30/2020. Role: Lead Site; Jason Adelman PI
- Providing Evidence and Developing a Toolkit to Accelerate the Adoption of Patient Photographs in Electronic Health Records (AHRQ R01). Study Period: 9/30/2017 – 7/31/2021. Role: Lead Site; Jason Adelman PI.
- Effectiveness of Pictographs to Prevent Wrong-Patient Errors in the NICU (NICHD R01). Study Period: 4/1/2018–3/31/2023. Role: Lead Site; Jason Adelman PI
- Columbia University Patient Safety and Health Services Research Training (AHRQ T32). Study Period: 7/1/18–6/30/23. Role: Multi-PI (Multi-PIs: Adelman, J; Barr, RG)
- Assessing the Risk of Wrong-Patient Errors in an EHR that Allows Multiple Records Open (AHRQ R21). Study Period: Completed, data analysis ongoing. Role: Lead Site; Jason Adelman PI
- Preventing Wrong-Drug and Wrong-Patient Errors with Indication Alerts in CPOE Systems (AHRQ R01). Study Period: 10/1/2016–9/30/2021. Role: Collaborating Site; Bruce Lambert PI; Jason Adelman Site Lead
- Generalizability and Spread of an Evidenced-based Fall Prevention Toolkit: Fall TIPS (AHRQ R18). Study Period: 4/1/2017–1/31/2020. Role: Collaborating Site; Patricia Dykes PI; Jason Adelman Site Lead
- Making Acute Care More Patient Centered (AHRQ P30). Study Period: 9/30/2014–9/29/2018. Role: Collaborating Site; Patricia Dykes PI; Jason Adelman Site Lead
- Reducing Diagnostic Errors in Primary Care Pediatrics (AHRQ R01). Study Period: 9/30/2014–9/29/2018. Role: Collaborating Site; Michael Rinke PI.
- Judy Aschner, MD
- David Bates, MD, MSc
- Eileen Carter, RN, PhD
- Allen Chen, MD, MPH
- Patricia Dykes, RN, PhD, MA
- William Galanter, MD, PhD
- Tejal Gandhi, MD, MPH
- Robert Green, MD, MPH, MS
- Bruce Lambert, PhD
- Lena Mamykina, PhD, MS
- William Marella, MBA, MMI
- Michael Rinke, MD, PhD
- Hojjat Salmasian, MD, PhD
- Gordon Schiff, MD
- William Southern, MD, MS
- David Vawdrey, PhD, MS
Adelman JS, Aschner JL, Schechter CB, Angert RM, Weiss JM, Rai A, Berger MA, Reissman SH, Yongue C, Chacko B, Dadlez NM, Applebaum JR, Racine AD, Southern WN. Evaluating Serial Strategies for Preventing Wrong-Patient Orders in the NICU. Pediatrics. 2017;139(5). PMID: 28557730.
Adelman JS, Aschner J, Schechter C, Angert R, Weiss J, Rai A, Berger M, Reissman S, Parakkattu V, Chacko B, Racine A, Southern W. Use of Temporary Names for Newborns and Associated Risks. Pediatrics. 2015;136(2):327-333. PMID: 26169429.
Adelman JS, Aschner JL, Schechter CB, Angert RM, Weiss JM, Rai A, Parakkattu V, Goffman D, Applebaum JR, Racine AD, Southern WN. Babyboy/Babygirl: A National Survey on the Use of Temporary, Nondistinct Naming Conventions for Newborns in Neonatal Intensive Care Units. Clin Pediatr (Phila). 2017:9922817701178. PMID: 28403654.
Adelman JS, Berger MA, Rai A, Galanter WL, Lambert BL, Schiff GD, Vawdrey DK, Green RA, Salmasian H, Koppel R, Schechter CB, Applebaum JR, Southern WN. A national survey assessing the number of records allowed open in electronic health records at hospitals and ambulatory sites. J Am Med Inform Assoc. 2017. PMID: 28419267.
Adelman JS, Chelcun J. Evidence-based safe surgical practices as adjuncts to the universal protocol. Arch Surg. 2011 Apr;146(4):489; author reply 489-90. PMID: 21502464.
Adelman JS, Kalkut GE, Schechter CB, Weiss JM, Berger MA, Reissman SH, Cohen HW, Lorenzen SJ, Burack DA, Southern WN. Understanding and preventing wrong-patient electronic orders: a randomized controlled trial. J Am Med Inform Assoc. 2013;20(2):305-310. PMID: 22753810.
Amato MG, Salazar A, Hickman TT, Quist AJ, Volk LA, Wright A, McEvoy D, Galanter WL, Koppel R, Loudin B, Adelman JS, McGreevey JD, 3rd, Smith DH, Bates DW, Schiff GD. Computerized prescriber order entry-related patient safety reports: analysis of 2522 medication errors. J Am Med Inform Assoc. 2017;24(2):316-322. PMID: 27678459.
Austrian JS, Adelman JS, Reissman SH, Cohen HW, Billett HH. The impact of the heparin-induced thrombocytopenia (HIT) computerized alert on provider behaviors and patient outcomes. J Am Med Inform Assoc. 2011;18(6):783-788. PMID: 21712374.
Bhalla R, Berger MA, Reissman SH, Yongue BG, Adelman JS, Jacobs LG, Billett H, Sinnett MJ, Kalkut G. Improving hospital venous thromboembolism prophylaxis with electronic decision support. J Hosp Med. 2013;8(3):115-120. PMID: 23184857.
Dadlez NM, Azzarone G, Sinnett MJ, Resnick M, Ushay HM, Adelman JS, Broder M, Duh-Leong C, Huang J, Kiely V, Nadler A, Nelson V, Simcik J, Rinke ML. Ordering Interruptions in a Tertiary Care Center: A Prospective Observational Study. Hosp Pediatr. 2017;7(3):134-139. PMID: 28148543.
Kannampallil TG, Manning JD, Chestek DW, Adelman JS, Salmasian H, Lambert BL, Galanter WL. Effect of number of open charts on intercepted wrong-patient medication orders in an emergency department. J Am Med Inform Assoc. 2017 Sep 11. PMID: 29025090.
Katsulis Z, Ergai A, Leung WY, Schenkel L, Rai A, Adelman JS, Benneyan J, Bates DW, Dykes PC. Iterative user centered design for development of a patient-centered fall prevention toolkit. Appl Ergon. 2016;56:117-126. PMID: 27184319.
Leung WY, Adelman JS, Bates DW, Businger A, Dykes JS, Ergai A, Hurley A, Katsulis Z, Khorasani S, Scanlan M, Schenkel L, Rai A, Dykes PC. Validating Fall Prevention Icons to Support Patient-Centered Education. J Patient Saf. 2017. PMID: 28230576.
Rinke ML, Singh H, Heo M, Adelman JS, O'Donnell HC, Choi SJ, Norton A, Stein REK, Brady TM, Lehmann CU, Kairys SW, Rice-Conboy E, Thiessen K, Bundy DG. Diagnostic Errors in Primary Care Pediatrics: Project RedDE. Acad Pediatr. 2018 Mar;18(2):220-227. PMID: 28804050.
Rinke ML, Singh H, Ruberman S, Adelman JS, Choi SJ, O'Donnell H, Stein RE, Brady TM, Heo M, Lehmann CU, Kairys S, Rice-Conboy E, Theissen K, Bundy DG. Primary care pediatricians' interest in diagnostic error reduction. Diagnosis (Berl). 2016;3(2):65-69. PMID: 28111611.
Dadlez NM, Adelman J, Bundy DG, Singh H, Applebaum JR, Rinke ML. Contributing Factors for Pediatric Ambulatory Diagnostic Process Errors: Project RedDE. Pediatric Quality and Safety. 2020.
Adelman JS, Applebaum JR, Schechter CB, et al. Effect of restricting of the number of concurrently open records in an electronic health record on wrong-patient order errors: a randomized clinical trial. JAMA. 2019;321(18):1780-1787. PMID: 31087021
Adelman JS, Applebaum JR, Southern WN, et al. Risk of Wrong-Patient Orders Among Multiple vs Singleton Births in the Neonatal Intensive Care Units of 2 Integrated Health Care Systems. JAMA Pediatr. 2019. PMID: 31449284
Adler-Milstein J, Adelman JS, Tai-Seale M, Patel VL, Dymek C. EHR audit logs: A new goldmine for health services research? J Biomed Inform. 2020;101. PMID: 31821887