Wrong-Patient Orders

While electronic health records (EHRs) are intended to improve patient care, some risks are increased over the old paper record. Charting On Wrong Patient In EHR (COWPIE) is one such risk. A recent study examining one component of that, Computerized Physician Order Entry (CPOE) has some interesting findings. And, as the authors state, increasing automation, while reducing the opportunities for human error, also reduces the opportunities for humans to identify an error and intervene.

In the children’s hospital studied, automated surveillance identified 644 probable CPOE COWPIEs. Only four had been reported to risk management, presumably events in which the wrong patient received the medication. The great majority of these events appeared to qualify as near misses, with the errant order rapidly cancelled and replaced with the correct order for the correct patient.

Risk factors included:

  • Age: infants and newborns were much more likely (2.9 and 3.6 times, respectively) to have wrong-patient orders.
  • Last name: two-letter overlap 4.4 times more likely.
  • Location: patients in nearby rooms 2.8 times more likely.
  • Day of week: Friday 2 times more likely than Monday.
  • Hour of day: midnight to 6 am 1.7 times more likely than 6 pm to midnight.
  • More physicians ordering for the patient: 1.4 times more likely.

It may be easier to pull the wrong patient’s chart in an electronic versus paper format, when only a few charts were at hand. Now all the charts in the system are readily available and may be pulled up by error. A standard approach should be taken to assuring that the correct chart is used when entering information

Hospitals may be interested in using this study’s surveillance method to identify their risks. In the study, they identified potential CPOE COWPIEs: if a provider 1) ordered a drug on a patient, 2) cancelled the order within 120 minutes, and 3) then reordered the same drug on a different patient within 5 minutes of cancellation, it is presumed to be an error. When the authors performed chart reviews on a subset of these automatically identified “errors”, they found that at least 60 percent and perhaps as many as 100 percent of the charts confirmed the error (documentation of the reasons for the provider’s actions often was ambiguous).

Mitigation strategies:

  • Ensure that providers habitually use two patient identifiers when entering orders into electronic health records, in compliance with the recommendations of the Joint Commission’s national patient safety goal 01.01.01.
  • For hospitals changing from paper to electronic charts, include in provider training information about how the risk for obtaining the incorrect chart is changing.
  • Limit, when practical, the list of available patient records for each provider. This may not be feasible in certain systems or situations and may produce other risks if not implemented with care.


Levin HI, Levin JE, Docimo SG. “I meant that med for Baylee not Bailey!”: a mixed method study to identify incidence and risk factors for CPOE patient misidentification. AMIA … Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 2012;2012:1294–301.

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