Toward our goal of advancing health services research that leads to replicable and scalable safety solutions, studies conducted by the Center for Patient Safety Research and Innovation have informed national recommendations and regulations issued by The Joint Commission, the Office of the Coordinator for Health Information Technology (ONC) in the Department of Health and Human Services, and the Children’s Hospital Association.

Development and Validation of the Wrong-Patient Retract-and-Reorder Measure

The Wrong-Patient RAR measure uses an electronic query to detect orders placed for a patient that are cancelled within 10 minutes, and then reordered by the same provider for a different patient within the next 10 minutes.

The Wrong-Patient Retract-and-Reorder (RAR) Measure, developed and validated by Adelman and colleagues, was the first Health IT Safety Measure endorsed by National Quality Forum (NQF Measure #2723). The Wrong-Patient RAR Measure using an electronic query to detect orders placed for a patient that are retracted within 10 minutes, and then reordered by the same provider for a different patient within the next 10 minutes. Real-time confirmatory telephone interviews with providers demonstrated that 76% of the RAR events identified by the measure were confirmed near-miss, wrong-patient orders. The Wrong-Patient RAR measure identified more than 5,000 orders placed on the wrong patient over a 1-year period in a large academic medical center, which translates to 58 wrong-patient orders per 100,000 orders. This means that 1 of 6 providers placed an order on the wrong patient and 1 of 37 inpatients had an order placed for them that was intended for another patient. Previously, voluntary reporting suggested that the average hospital experienced 9 wrong-patient orders per year.

Results of this study led to national patient safety recommendations in the Patient Identification SAFER Guide issued by ONC, which recommends that healthcare organizations use the Wrong-Patient RAR Measure to monitor the frequency of wrong-patient orders.

Distinct Naming Convention Reduces Wrong-Patient Orders in the Neonatal Intensive Care Unit (NICU)

Adelman and colleagues used the RAR Measure to test a simple, replicable, and scalable intervention to reduce the risk of wrong-patient orders in the NICU. We conducted a before-after study in a 50-bed NICU in a large academic medical center, using the RAR Measure to identify the outcome. Our intervention replaced the newborn naming convention typically used by hospitals (e.g., Babyboy/Babygirl) with a more distinct naming convention that incorporated the mother’s first name (e.g., Wendysboy/Wendysgirl). For multiple births (twins, triplets, and higher-order multiples), a number was added before the first name to distinguish siblings (e.g., 1Wendysgirl, 2Wendysgirl). Adoption of the distinct naming convention significantly reduced the odds of near-miss, wrong-patient orders in the NICU by 36%.

Nondistinct  Naming  Convention
Distinct Naming Convention
Babygirl Jackson Wendysgirl Jackson
Babygirl Johnson Brendagirl Johnson
Babygirl Jones Catherinesgirl Jones

Temporary names are made more distinct by incorporating the mother’s first name into the newborn’s first name. MRN, Medical Record NumberResults of this study had far-reaching impact: The Joint Commission and the Children’s Hospital Association issued recommendations that hospitals adopt the distinct naming convention for newborns and the leading EHR vendor Epic adopted the distinct naming convention as its standard. In addition, the Joint Commission released a requirement, effective January 2019, that all hospitals use the distinct naming convention for identifying newborns as part of its National Patient Safety Goals.

ID Verification Alerts for Preventing Wrong-Patient Orders

Adelman and colleagues used the RAR Measure to test the effect of alerts that prompt providers to verify patients’ identity prior to placing orders. We conducted a three-arm randomized controlled trial in a large hospital system in which providers were randomly assigned to one of two interventions or control (no intervention).The first intervention arm was an ID-verify alert that displayed the patient’s name, gender, and age on opening the order screen, and providers could proceed only after a single click to verify the patient’s identity. The second intervention arm was an ID-reentry function, which blocked access to the order screen until the provider reentered the patient’s initials, gender, and age. Both interventions significantly reduced the odds of placing a wrong-patient order, the ID-verify alert by 16% and the ID-reentry function by 41% compared to no intervention.

Based on results of this study, the ONC Patient Identification SAFER Guide recommends that providers enter patients’ initials prior to signing an order in the EHR.