Wrong-patient order entry (WPOE) represents an important type of error. Although studies indicate that practitioners place more than 99.9% of all orders for the correct patient, the large number of orders placed by practitioners each day suggests that even an error rate of less than 1 in 1000 orders would still lead to approximately 600,000 orders placed for the wrong patient annually.
Strategies to reduce WPOE have focused on improving patient identification by interrupting practitioners during electronic order entry. These strategies include a patient verification alert or an electronic form in which the practitioner must enter certain patient identifiers (i.e., medical record number or first and last initials) to confirm the patient’s identity. Alerts can include warnings about patients with similar names because this issue is associated with a higher risk of WPOE errors. However, these interruptive solutions risk slowing practitioners’ workflow, and multiple exposures to electronic alerts can reduce the practitioners’ engagement with the alerts also known as alert fatigue. One such strategy is to display the patient’s photograph in the electronic health record (HER). This solution is based on evidence that humans are good at recognizing familiar faces. In a study where patient photographs were displayed in the banner of the EHR, there was a statistically significant reduction of WPOE errors. Most of us keep current resident photos in our medical records for this very reason, kind of nice that for once we are ahead of the studies! Nice job! Stay the course, stay strong, stay well, mask up, and stay tuned!