Using Health IT to Spot—and Stop—Wrong-Patient Errors

“I'm on the verge of making a set of new patient safety measures to address the five rights of medication safety. And we’ll finally have rigorous evidence about using patients’ photos to reduce wrong-patient errors. None of that would have been possible without funding and support from AHRQ.”

As a young patient safety officer, Jason Adelman, M.D., M.S., first became interested in using health information technology (IT) to prevent wrong-patient errors when an elderly female patient was mistakenly given a high dose of methadone intended for a young male heroin addict.

Now, as the Chief Patient Safety Officer and Vice Chair for Quality and Patient Safety at Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, Dr. Adelman combines his clinical, operations, and research skills to help health systems identify and reduce the risk of medical errors and adverse events.

AHRQ support is helping him realize these goals. The Agency has funded several large-scale studies to develop and validate health IT patient safety measures and to use these measures to evaluate interventions aimed at making electronic health record (EHR) systems safer.

Laying the groundwork following the tragic wrong-patient incident, Dr. Adelman developed the first health IT patient safety measure endorsed by the National Quality Forum. It uses an electronic query to quickly identify near-miss wrong-patient orders, when a clinician places an order, retracts the order, and then places the same order for a different patient. In just one year of testing, the measure identified more than 5,000 orders placed on the wrong patient.

Not only did the measure reveal a much larger volume of wrong-patient orders than physicians’ voluntary reporting identified, it also showed that “there are many more near-miss errors than errors that reach the patient,” Dr. Adelman said. That’s important, because near-miss errors “have the same causal pathway as those that can cause harm,” and can show where root causes of errors exist. The large number of near-miss errors also makes it possible to test preventive strategies.

Expanding on the initial wrong-patient measure, one of his AHRQ-funded studies is testing a complete set of automated measures to capture violations of the “five rights” of medication safety: right patient, right dose, right medication, right route, and right frequency.

According to Dr. Adelman, emerging data show a significant number of violations identified by the wrong-dose measure,  a finding that could hold especially promising impact for pediatric medication safety. “A newborn baby can weigh three pounds, and an overweight teenager can weigh 300 pounds. Pediatricians have to dose for these children and all those in between.”

The five measures are being implemented and validated to confirm that they flag true events, not false alarms. They have been validated in an Allscripts EHR and are now being tested in an Epic EHR to ensure reliability across systems.

Dr. Adelman is also heading an AHRQ-funded study that seeks to find out whether wrong-patient errors can be reduced by displaying patient photos in EHRs. Only 20 percent of hospitals have adopted this policy, citing a lack of evidence and difficulty in implementation.

In this randomized controlled trial conducted at Columbia University Irving Medical Center, Weill Cornell Medicine, and Johns Hopkins Medicine, providers will view order entry screens that appear with or without a patient photo. Preliminary data from the study, which has been delayed due to the use of face masks during COVID-19, indicate that the rate of wrong-patient errors is lower among providers using EHRs with patient photos. Once the study is completed, Dr. Adelman and his team will develop a toolkit that provides guidance on how to implement patient photos in EHRs.

Although Dr. Adelman’s research shows that health IT interventions can reduce the risk of wrong-patient errors, his first AHRQ-funded grant demonstrated why evidence—even when it challenges conventional wisdom—should come first. In this study funded in 2014, the rate of wrong-patient errors was compared between providers who were limited to one patient record open in the EHR and  those working with up to four patient records. At the time, health IT and quality improvement groups were split over the patient safety benefit of limiting the number of open patient records.

The study results, reported in JAMA in 2019, found no significant difference in wrong-patient orders, regardless of the number of open patient records. However, it did suggest the true risk of wrong-patient errors may be interruptions. Notes Dr. Adelman, “If we can’t solve the interruption problem, at least we can have visual cues, such as patient photos, to stop wrong-patient errors from reaching patients.”

He credits his AHRQ funding, including support through an ongoing post-doctoral health services and patient safety research training program at Columbia University, with helping to address the many complex issues surrounding medical errors and to train new investigators in the field. “It has given me opportunities to pursue research that otherwise hadn’t been done, and to find solutions to problems that otherwise wouldn’t have been possible.”

In 2022, Dr. Adelman received the John M. Eisenberg Patient Safety and Quality Award from the National Quality Forum and The Joint Commission. 

Principal Investigator: Jason S. Adelman, M.D., M.S.
Institution: Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York
Grantee Since: 2014
Type of Grant: Various

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