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Title The Use of Patient Pictures and Verification Screens to Reduce Computerized Provider Order Entry Errors
Author(s) Daniel Hyman, MD, MMM Mariel Laire, BA, MBA, Diane Redmond, MSN, CPHQ, RN, and David W. Kaplan, MD, MPH
Source Pediatrics, Vol. 130, No. 1, Pages 211-219
Publication Date 1-Jul-12
Abstract OBJECTIVE: To determine whether an order verification screen, including a patient photograph, is an effective strategy for reducing the risk that providers will place orders in an unintended patient’s electronic medical record (EMR). METHODS: We describe several changes to the EMR/provider interface and ordering workflow that were implemented as one part of a hospital-wide quality improvement effort to improve patient identification and verification practices. We measured the impact by comparing the number of reported incidents of care being provided to any patient other than for whom it was intended before the intervention, and directly after the intervention. RESULTS: For the year before the interventions described herein, placement of orders in the incorrect patient’s chart was the second most common cause of care being provided to the wrong patient, comprising 24% of the reported errors. In the 15 months after the implementation of an order verification screen with the patient’s photo centrally placed on the screen, no patient whose picture was in the EMR was reported to have received unintended care based on erroneous order placement in his or her chart. CONCLUSIONS: The incorporation of patient pictures within a computerized order entry verification process is an effective strategy for reducing the risk that erroneous placement of orders in a patient’s EMR will result in unintended care being provided to an incorrect patient.


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