American College of Physicians: Internal Medicine — Doctors for Adults ®


Facing the problem of patient ID errors

From the March ACP Hospitalist, copyright © 2013 by the American College of Physicians

By Stacey Butterfield

Where: Children's Hospital Colorado, a 318-bed pediatric academic medical center in Aurora, Colo.

The issue: Reducing errors in computerized provider order entries.


Electronic medical records have made many things easier, including making certain kinds of errors. In 2009, leaders at Children's Hospital Colorado began analyzing adverse events and near-misses related to patient misidentification.

“A surprise, as we were reviewing the events and near-misses related to patient identification, was that the second most common root cause of these events was providers placing orders in the wrong patient's medical record,” said Daniel Hyman, MD, MMM, chief quality officer at the hospital. “In ten cases, providers placed orders in an unintended patient's record resulting in care errors. In addition, 30 near-misses were reported in which nurses recognized that an order had been placed in a patient's chart and did not seem consistent with the plan of care. They questioned the provider, who redirected the errant order to the correct patient.”

To reduce these incidents, hospital leaders considered a number of changes, including restricting the number of charts that a clinician could have open on a computer at one time. “But we really couldn't prove that more than one chart was open at any of the times that these errors were placed [and] there were significant concerns about workflow. People are sometimes working in more than one chart for good reason,” said Dr. Hyman.

Instead, they added a verification step, which asks ordering clinicians to confirm the patient's identity. “We had a screen pop up when people signed orders, saying, ‘You're signing orders on Dan Hyman’ [for example],” said Dr. Hyman. “But we were continuing to have events and near-misses, so we pretty quickly went to adding the patient's picture.”

How it works

In late 2010, the hospital began taking digital photos of patients when they were first admitted or registered. The photo is embedded in the patient's electronic medical record (EMR) and appears on a verification screen that the clinician must acknowledge to finish the ordering process. “If you think you're writing an order on a teenage girl, and a picture of a four-month-old baby shows up, it's jarring. People respond to these kinds of alerts differently than they do other sorts of [EMR] advisories,” said Dr. Hyman.


Adverse event data collected at the hospital after implementation of the photos revealed a robust response to the change. “We went 15 months or so after the introduction of the pictures without having a single patient whose picture was in the record receive unintended care due to an ordering error in the wrong chart,” said Dr. Hyman.

During 2011, photos were attached to about 95% of patient records, according to results published in the July 1, 2012 Pediatrics. Among the 5% who didn't have photos, there were three reports of misplaced orders, a sign that the photos were making an impact.

The effects were dramatic and sustained, Dr. Hyman said, which has reassured project leaders that this alert won't succumb to clinicians' usual fatigue with warnings and pop-ups. “Over two-plus years, we've had two events as opposed to 10 during the year prior,” Dr. Hyman said. “Because of its prominence visually, it has a different effect than a normal yellow box alert. You don't have to read anything….It's just a visual cue.”


The major requirements of the project were modification of the electronic medical record by the hospital's information technology department and investment in photography equipment and time. “It ended up being a lot of work. We had to install cameras everywhere. We had to go through the workflow for all of the registration staff to take pictures,” said Dr. Hyman. “But…people accepted it very quickly.”


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