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Montefiore in the News

September 22, 2014

$300,000 Grant Will Fund Research to Determine Risk of Wrong Patient Electronic Errors

NEW YORK (September 22, 2014) –Montefiore Medical Center, Albert Einstein College of Medicine of Yeshiva University and Brigham and Women’s Hospital have received a $300,000 grant from The Agency for Healthcare Research and Quality (AHRQ) to study the impact of health Information Technology (IT) on patient safety.

This research will directly address “wrong patient” electronic orders, an important clinical patient safety issue impacted by health IT. Upon completion of the study, it will be the first time IT leaders have data on the risk of “wrong patient” errors when a varying number of clinical records are opened at once. This information will help determine the best format for their computerized provider order entry (CPOE) systems.

“CPOE systems have been shown to prevent many types of medical errors, but certain types of errors occur frequently in these systems, including placing orders on the wrong patient,” said Jason Adelman, M.D., M.S., patient safety officer at Montefiore Medical Center, assistant professor of medicine at Einstein, and principal investigator on the grant. “We propose to do a prospective, observational study that examines the relationship between the number of records open at the time of placing an order and the risk of placing an order on the wrong patient.”

The research also will include a two-armed crossover pilot study that evaluates the wrong patient error rate when the system is configured to allow only one record open at a time compared to a system configured to allow a maximum of four records to be open at one time.

A national survey of Chief Medical Information Officers conducted by Montefiore Medical Center in March 2014 previously demonstrated the lack of consensus on the safest number of patient records being opened at once.  Of the 91 respondents, 76 had CPOE systems capable of simultaneously displaying multiple patient records.  Among these 76 respondents, there was marked heterogeneity in the number of records allowed open by IT leadership, with several hospitals changing their settings after the initial configuration. Some changed their system to allow more records open, while others decided to limit their system to only one record at a time.

This study is made possible by an innovative tool developed at Montefiore. The Retract-and-Reorder tool, which detects orders placed on a patient that are retracted within 10 minutes and then placed by the same clinician on a different patient, detects wrong patient orders that are “near miss” events. This tool will be used to identify the primary outcome measures for both the prospective, observational study as well as the two-armed crossover pilot study.

The grant is part of $4 million funding from the United States Congress to finance AHRQ’s support for research on health IT’s impact on patient safety.

Additional investigators included from Montefiore-Einstein: Will Southern, M.D., M.S., Matthew Berger, M.D., Paul Meissner, M.S.P.H., and Parsa Mirhaji, M.D., Ph.D.; from Einstein: Clyde Schechter, M.D.; From Brigham and Women's: Gordon Schiff, M.D., David Bates, M.D., and Adam Wright, Ph.D.