ComputingHealth InformaticsClinical InformaticsPatient SafetyRisk AssessmentAdverse Drug Event ReportingMedication ErrorsMedication Management SystemsMedication SafetyOrder EntryPatient Safety AnalyticsAdverse Drug EventsHigh-risk SituationsMedication Order EntryMedication OrderingMixed Methods Case StudyOrder Entry ErrorsPatient Misidentification ErrorsPhysician Order Entry
Computerized physician order entry (CPOE) systems can create unintended consequences. These include medication errors and adverse drug events. We look at a less understood error; patient misidentification. First, two email surveys were used to establish potential risk factors for this error. Next, an automated detection trigger was designed and validated with inpatient medication orders at a large pediatric hospital. The incidence was 0.064% per medication ordered. Finally, a case-control study identified the following as significant risk factors on multivariate analysis: patient age, last name spelling, bed proximity, medical service, time/date of order, and ordering intensity. These results can be used to improve patient safety by increasing awareness of high risk situations and guiding future research.
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