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Error Alert: Placing Orders on the Wrong Patient’s EHR

February 21, 2016


It would be an incredibly difficult and a near impossible task to list all the risks associated with medication use that could lead to harmful medication errors. This is often at the heart of wondering where to start to improve medication safety, and why people frequently resort to playing “whack-a-mole,” addressing risks only after they pop up and become visible after an adverse event. It’s also one of the primary reasons the Institute for Safe Medication Practices (ISMP) has established the Targeted Medication Safety Best Practices for Hospitals—to help create a sharp lens with which to focus improvement efforts on a few best practices that we are confident will prevent patient harm.

In this blog we will describe other selected medication safety risks that might otherwise fall off the radar screen unless an adverse event happens to draw attention to them. Again, there is an overabundance of risks to choose from, but we thought these particular, serious risks may not otherwise garner attention without mention.

We have selected one risk from each of ISMP’s 10 Key Elements of the Medication Use System™ as vulnerabilities in these system elements cause errors.


Now that most hospitals and doctors’ offices have implemented electronic health records (EHRs), a potentially hidden vulnerability that can lead to serious errors is placing orders on the wrong patient’s electronic record. Using a unique retract-and-reorder tool, which identifies orders placed on a patient’s electronic record that are then retracted and reordered on a different patient’s electronic record, Adelman et al. were able to identify and quantify close calls that would have resulted in wrong-patient errors but may never have been reported as such. According to this study, about 14 wrong-patient electronic orders are placed every day in a large hospital system with approximately 1,500 beds, or about 68 wrong-patient errors per 100,000 medication orders. By this measure, 1 in 37 hospitalized patients will have an order placed for them that was intended for another patient.

These errors—made not only by prescribers but also by pharmacists and nurses who enter orders—are sometimes due to juxtaposition but more often caused by interruptions and having more than one patient’s electronic record open. Interestingly, nurses have a lower rate of this type of error, while radiology and outpatient providers have higher error rates than their comparison groups.

Multiple studies have demonstrated ways to reduce these events. Requiring verification of the patient’s identity (ID) has reduced errors by 16% to 30%, and requiring reentry of the patient’s ID has reduced errors by 41%. Prompting clinicians for an indication when certain medications are ordered without an indication on the patient’s problem list has intercepted errors at a rate of 0.25 per 1,000 alerts.

In another study, clinicians had confidence that the following interventions would significantly reduce wrong-patient entries: including a patient’s photo on order entry screens; showing the patient’s location based on a unit floor plan; providing alerts about similar names; using RFID (radio-frequency identification) technology; always showing the patient’s full name on screens; requiring reentry of the patient’s ID; and including the identity of the patient with the order submit button. Limiting the number of patient electronic records that can be opened at one time is also recommended; its ability to reduce errors is currently under study.

Has your organization discovered problems with entering orders into the wrong patient profiles? What steps have you taken to reduce the incidence of wrong patient errors?


Matthew Grissinger, RPh, FISMP, FASCP, is the Director of Error Reporting Programs at the Institute for Safe Medication Practices.



1. Galanter W, Falck S, Burns M, Laragh M, Lambert BL. Indication-based prescribing prevents wrong-patient medication errors in computerized provider order entry (CPOE). J Am Med Inform Assoc. 2013;20(3):477-481.

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