Currently, at least 70,000 U.S. physicians use computerized provider order entry (CPOE) to
place orders. This number is expected to rise sharply as hospitals continue to take advantage
of federal incentives and adopt electronic health record (EHR) technology. Although CPOE is
associated with a reduction in medical errors, when orders are placed electronically certain
types of errors, including placing orders on the wrong patient, may occur more frequently.
The mechanism by which multiple patient records opened simultaneously can lead to
wrong-patient errors may be related to the ease with which users can toggle between patient
records and the similar looking computer screens. The magnitude of this risk needs to be
established to help Health Information Technology (IT) leadership decide how to safely
implement CPOE systems. There have been no studies demonstrating whether multiple records
increase the risk of wrong-patient errors, by how much, and if any increase is dependent on
the number of records open. This research project is an important first step in quantifying
this risk.This will be the first study to achieve the following aims:
1. Assess 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.
2. Compare the incidence of wrong-patient orders in a "restricted environment" that limits
providers to only one record open at a time to an "unrestricted environment" where users
can open a maximum of four records at once.
3. Use results to inform a larger-scale health IT implementation research project
evaluating the balance between the wrong-patient error risks and potential efficiency
gains of having multiple records open at once, with rigorous research methodologies.
4. Disseminate results to help inform decisions on how to safely implement EHR systems.