Entering orders for the wrong patient is a potentially deadly type of medical error, but the simple step of adding patient photographs to their EHRs can help clinicians avoid this misstep, a new study shows.
Wrong-patient errors — which occur when a provider means to place an order for one patient but places it for another by mistake — happen rarely, less than 1% of the time, Dr. Hojjat Salmasian, lead author of the study and medical director of data science and analytics at Brigham Health, said in an email. But providers place millions of orders every year so that small percentage still results in hundreds of thousands of these errors annually, previous research shows.
“Even though most wrong-patient errors are quickly identified and corrected, there are known cases where they reached the patient and caused serious harm. Therefore, wrong-patient errors are considered a serious type of medical error,” Salmasian said.
To combat this error, Salmasian and his team decided to study the impact of an intervention that involved adding patient photos to their EHRs. They found that when the photo was stored in the EHR and displayed in the patient’s chart, the risk of wrong-patient errors was lowered substantially.
Published in JAMA Network Open, the study was conducted at Boston-based Brigham and Women’s Hospital. The hospital implemented the quality improvement initiative in its emergency department, which includes 59 acute care and observation beds and has an annual volume of around 60,000 patient visits. Researchers gathered data on patients who received care in the ED between July 1, 2017, and June 31, 2019.
Overall, researchers analyzed 2.5 million patient orders placed for 71,851 patients. Of the total number of orders, 596,346 (23.3 percent) were placed with the patient’s photo displayed to the practitioner.
They found that the rate of wrong-patient errors was 35 percent lower for patients who had their photos displayed.
One somewhat surprising finding of the study was the risk of wrong-patient errors was lower in patients whose race was documented as white.
“We were not exactly surprised by this, as the difference was small, and the possibility of differences based on race was certainly something we had considered,” Salmasian said. “Our current data is not sufficient for us to able to speak with certainty about the source of this difference. This may illuminate implicit bias, treatment inequities and the patient care impact of having a predominantly white patient population.”
Conducting the study was not without its challenges. Though patients have always been able to upload their photo to their EHRs via their online portal, few did so in the past, Salmasian said.
For the study, ED staff were told to speak with patients about adding their photo to their EHR. If the patient agreed, staff would take their picture and upload it.
The researchers knew that they would not get a photo for all patients who came to the ED, due to the urgent and busy nature of work in the department and the fact that some patients would not consent to their photo being taken. But to get as many patient photos as possible, Salmasian’s team worked closely with the patient registration staff and managers and “supported them with analytics and dashboards,” he said.
Photo: pandpstock001, Getty Images