• Philip L Henneman, Donald L Fisher, Elizabeth A Henneman, Tuan A Pham, Yi Y Mei, Rakesh Talati, Brian H Nathanson, and Joan Roche.
• Department of Emergency Medicine, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA, USA. philip.henneman@bhs.org
• Acad Emerg Med. 2008 Jul 1; 15 (7): 641-8.

IntroductionImproving patient identification (ID), by using two identifiers, is a Joint Commission safety goal. Appropriate identifiers include name, date of birth (DOB), or medical record number (MRN).ObjectivesThe objectives were to determine the frequency of verifying patient ID during computerized provider order entry (CPOE).MethodsThis was a prospective study using simulated scenarios with an eye-tracking device. Medical providers were asked to review 10 charts (scenarios), select the patient from a computer alphabetical list, and order tests. Two scenarios had embedded ID errors compared to the computer (incorrect DOB or misspelled last name), and a third had a potential error (second patient on alphabetical list with same last name). Providers were not aware the focus was patient ID. Verifying patient ID was defined as looking at name and either DOB or MRN on the computer.ResultsTwenty-five of 25 providers (100%; 95% confidence interval [CI] = 86% to 100%) selected the correct patient when there was a second patient with the same last name. Two of 25 (8%; 95% CI = 1% to 26%) noted the DOB error; the remaining 23 ordered tests on an incorrect patient. One of 25 (4%, 95% CI = 0% to 20%) noted the last name error; 12 ordered tests on an incorrect patient. No participant (0%, 0/107; 95% CI = 0% to 3%) verified patient ID by looking at MRN prior to selecting a patient from the alphabetical list. Twenty-three percent (45/200; 95% CI = 17% to 29%) verified patient ID prior to ordering tests.ConclusionsMedical providers often miss ID errors and infrequently verify patient ID with two identifiers during CPOE.

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