ClinicalTrials.Veeva

Menu

Investigating Wrong-Patient Computerized Physician Order Entry (CPOE) Errors

Montefiore Medicine Academic Health System logo

Montefiore Medicine Academic Health System

Status

Completed

Conditions

Wrong Patient Computerized Physician Order Entry Errors

Treatments

Other: Control
Other: Passive Intervention
Other: Active Intervention

Study type

Interventional

Funder types

Other

Identifiers

NCT01262053
10-05-156E

Details and patient eligibility

About

With the increased adoption of CPOE systems, it is important to recognize that design flaws have resulted in the creation of new types of iatrogenic medical errors. An example of a new type of iatrogenic medical error introduced by CPOE systems has been named "juxtaposition errors". Juxtaposition errors, as defined by Ash, et al. are "errors that can result when something is close to something else on the screen, and the wrong option is too easily clicked in error." Juxtaposition errors can lead to a patient receiving a medication, a test, or a treatment intended for another patient, sometimes with dire consequences. Juxtaposition errors are likely a subclass of a broader group of wrong-patient CPOE errors that have multiple etiologies.

The primary objectives of this research proposal is to investigate the prevalence of wrong-patient near miss CPOE errors, to investigate the root cause of these errors, and to investigate and compare the efficacy and workflow impact of two distinct interventions to prevent these errors.

Full description

Computerized Physician Order Entry (CPOE) systems have been shown to prevent medical errors, and have become a major component of the patient safety movement. To accelerate the adoption of clinical information technology including CPOE systems, the American Recovery and Reinvestment Act of 2009 allocated approximately $17 billion as incentive payments to providers and hospitals who implement health information technology. With the increased adoption of CPOE systems, however, it is important to recognize that design flaws have resulted in the creation of new types of iatrogenic medical errors. In addition, CPOE systems developed with suboptimal and onerous user interfaces have contributed to entire systems being rejected by physicians. The ideal CPOE system maximizes medical error reduction, minimizes medical error creation, and has a user friendly interface that is accepted by nurses, physicians, and pharmacists.

An example of a new type of iatrogenic medical error introduced by CPOE systems has been named "juxtaposition errors" . Juxtaposition errors, as defined by Ash, et al. are "errors that can result when something is close to something else on the screen, and the wrong option is too easily clicked in error." Juxtaposition errors can lead to a patient receiving a medication, a test, or a treatment intended for another patient, sometimes with dire consequences.

Juxtaposition errors are likely a subclass of a broader group of wrong-patient CPOE errors that have multiple etiologies. Other possible causes of wrong-patient CPOE orders include interruption errors, or double-interruption errors.

Primary Objectives:

Specific Aim 1: Investigate the prevalence of wrong-patient near miss CPOE errors. Specific Aim 2: Investigate the root cause of wrong-patient near miss CPOE errors. Specific Aim 3: Investigate and compare the efficacy and workflow impact of two distinct interventions to prevent wrong-patient near miss CPOE errors against a control.

Enrollment

4,028 patients

Sex

All

Volunteers

No Healthy Volunteers

Inclusion criteria

  • All providers that place order in the Computerized Physician Order Entry (CPOE) System

Exclusion criteria

  • none

Trial design

Primary purpose

Other

Allocation

Randomized

Interventional model

Factorial Assignment

Masking

Single Blind

4,028 participants in 3 patient groups

Passive Intervention
Experimental group
Description:
When a user is about to place orders on a patient, a pop up alert will show the user the name, age, sex, room number and MR# of the patient who is currently activated.
Treatment:
Other: Passive Intervention
Active Intervention
Experimental group
Description:
The user will be required to enter the initials, age and sex of the activated patient prior to placing any orders.
Treatment:
Other: Active Intervention
Control
Active Comparator group
Description:
Parallel control with no intervention
Treatment:
Other: Control

Trial contacts and locations

1

Loading...

Data sourced from clinicaltrials.gov

Clinical trials

Find clinical trialsTrials by location
© Copyright 2024 Veeva Systems