While the vast majority of orders are placed correctly, typically 99.9%, the remaining 0.1% can do a lot of harm if they’re wrong. Aware of this issue, researchers at Brigham and Women’s Hospital decided to dig into these problematic orders, particularly those directed to the wrong patients.
As part of a quality improvement program aimed at improving patient safety, Brigham saw to it that the EHR included headshots for participating patients. This built on smaller-scale studies looking at how patient photos could decrease wrong patient order entry.
To conduct the study, researchers worked in the Emergency Department, which, given how common multitasking is there, has a higher rate of errors than other departments of the hospital. The study involved looking at a retrospective cohort of patients admitted between July 2017 and June 2019, in which photos taken of willing patient participants and corresponding orders placed were reviewed to see where errors could be found.
They found that of 2.5 million total orders placed across 71,851 patients. After analyzing the millions of orders placed for those patients over a two-year span, researchers found that the rate of wrong patient order entry to be 35% lower for patients whose photos were included in the EHR.
Interestingly, the reduction in error risk was slightly more defined among white patients, a finding which suggests that implicit bias and treatment inequities continue to play a role in care processes.
This study follows on an effort in which pop-up alerts were used to reduce wrong-patient errors. What makes this approach different, researchers noted, was that patient photos don’t interrupt navigation, and what’s more, leverages human skills at facial recognition.
Of course, with the pandemic continuing, patients and providers are wearing masks, which makes wider implementation of this approach largely impossible.
However, going forward it seems likely that the impact of cues like patient photos will continue to be worth studying. Putting photos in place seems to be amazingly effective for such a lightweight method.
As things stand, hospital EHRs frequently miss harmful or potentially fatal errors, according to one study. To conduct the study, which was published in the journal JAMA Network Open, researchers looked at 8,657 observations using a tool designed by investigators at Brigham and the University of Utah. It found that despite EHR optimization in hospitals, there’s still a great deal of variation in the safety performance of EHR CPOE systems.
However, it’s possible that some fixes aren’t that difficult to implement. While we might not know what they are yet, it seems likely that there are other simple approaches to matching patients with orders which could have a very significant impact on patient well-being.
Particularly once the COVID-19 pandemic begins to recede, it seems like a good idea to explore other ways of using basic EHR capabilities to keep patients safe.