Trial reportJournal of the American Medical Informatics Association : JAMIA
Understanding and preventing wrong-patient electronic orders: a randomized controlled trial.
Trial report in Journal of the American Medical Informatics Association : JAMIA. The graph could read no effect estimate from its abstract, so it casts no vote on the map. It is linked to 3 registered trials, which are not on this map. Cited by 60 papers, 6 of them syntheses that pooled it.
What it found
Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.
The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Assessing the Risk of Wrong-Patient Errors in an Electronic Health Record That Allows Multiple Records Open
A Randomized Controlled Trial Evaluating the Effectiveness of Displaying Patient Photographs in an Electronic Health Record to Prevent Wrong-Patient Electronic Orders
Assessing the Effectiveness of Pictographs for Preventing Wrong-Patient Errors in Neonatal Intensive Care Units: A Randomized Controlled Trial
Who cites it
60 citing papers in PubMed, 6 syntheses or guidelines pooled it.
- Reducing medication errors for adults in hospital settings.The Cochrane database of systematic reviews · 2021Pooled it
- The impact of health information technology on prescribing errors in hospitals: a systematic review and behaviour change technique analysis.Systematic reviews · 2020Pooled it
- Computer-generated reminders delivered on paper to healthcare professionals: effects on professional practice and healthcare outcomes.The Cochrane database of systematic reviews · 2017Pooled it
- A systematic review of the types and causes of prescribing errors generated from using computerized provider order entry systems in primary and secondary care.Journal of the American Medical Informatics Association : JAMIA · 2017Pooled it
- Interventions for reducing wrong-site surgery and invasive clinical procedures.The Cochrane database of systematic reviews · 2015Pooled it
- The effects of on-screen, point of care computer reminders on processes and outcomes of care.The Cochrane database of systematic reviews · 2009Pooled it
- Trial
- A framework for developing, validating, and utilizing automated measures of order errors using the retract-and-reorder methodology.JAMIA open · 2026Article
- Article
- Wrong-side imaging orders: automated detection using electronic health record data - a retrospective cohort study.BMJ open quality · 2026Article
- Article
- Unlocking inpatient workload insights with electronic health record event logs.Journal of hospital medicine · 2025Article
- Secure Messaging Use and Wrong-Patient Ordering Errors Among Inpatient Clinicians.JAMA network open · 2024Article
- Article
- Article
- Diagnostic Errors in Obstetric Morbidity and Mortality: Methods for and Challenges in Seeking Diagnostic Excellence.Journal of clinical medicine · 2024Review
- Retrospective cohort study of wrong-patient imaging order errors: how many reach the patient?BMJ quality & safety · 2024Article
- Acceptability of pictographs as a novel patient identifier to improve patient safety in the neonatal intensive care unit.AMIA ... Annual Symposium proceedings. AMIA Symposium · 2024Article
- Automated search methods for identifying wrong patient order entry-a scoping review.JAMIA open · 2023Article
- Safety of Health Care in the Inpatient Setting.The New England journal of medicine · 2023Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
10 authors.
Funding
Abstract
objectiveTo evaluate systems for estimating and preventing wrong-patient electronic orders in computerized physician order entry systems with a two-phase study. MATERIALS AND
methodsIn phase 1, from May to August 2010, the effectiveness of a 'retract-and-reorder' measurement tool was assessed that identified orders placed on a patient, promptly retracted, and then reordered by the same provider on a different patient as a marker for wrong-patient electronic orders. This tool was then used to estimate the frequency of wrong-patient electronic orders in four hospitals in 2009. In phase 2, from December 2010 to June 2011, a three-armed randomized controlled trial was conducted to evaluate the efficacy of two distinct interventions aimed at preventing these errors by reverifying patient identification: an 'ID-verify alert', and an 'ID-reentry function'.
resultsThe retract-and-reorder measurement tool effectively identified 170 of 223 events as wrong-patient electronic orders, resulting in a positive predictive value of 76.2% (95% CI 70.6% to 81.9%). Using this tool it was estimated that 5246 electronic orders were placed on wrong patients in 2009. In phase 2, 901 776 ordering sessions among 4028 providers were examined. Compared with control, the ID-verify alert reduced the odds of a retract-and-reorder event (OR 0.84, 95% CI 0.72 to 0.98), but the ID-reentry function reduced the odds by a larger magnitude (OR 0.60, 95% CI 0.50 to 0.71). DISCUSSION AND
conclusionWrong-patient electronic orders occur frequently with computerized provider order entry systems, and electronic interventions can reduce the risk of these errors occurring.
Indexed as
Identifiers
What OpenQuestion holds
Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.