N/A N=3,356 Randomized Other

Risk of Wrong-Patient Errors With Multiple Records Open

Medical Errors · Medical Order Entry Systems

Bottom Line

View on ClinicalTrials.gov: NCT02876588 ↗

Enrolled (actual)

3,356

Serious AEs

0.0%

Results posted

Feb 2025

Primary outcome: Primary: Wrong-patient Order Sessions, Defined as Order Sessions That Include at Least One Wrong-Patient Retract-and-Reorder (RAR) Event, As-randomized Analysis — 3015; 3058 Wrong-patient order sessions — p=.60

Study Design & Population

Study type: Interventional
Phase: N/A
Interventions: Unrestricted (Other); Restricted (Other)
Age: Adult, Older Adult · 21+ yrs
Sex: All
Sponsor: Columbia University
Primary completion: Apr 2017

Outcome Measures

Outcome	Result	p-value
PRIMARY Wrong-patient Order Sessions, Defined as Order Sessions That Include at Least One Wrong-Patient Retract-and-Reorder (RAR) Event, As-randomized Analysis	3015; 3058	.60
SECONDARY Wrong-patient Order Sessions, Defined as Order Sessions That Include at Least One Wrong-Patient Retract-and-Reorder (RAR) Event, as Treated Analysis	3091; 2982	.68

Summary

This study is designed to achieve the following aims: 1. Assess the relationship between the number of records open at the time of placing an order, and the risk of placing an order on the wrong patient. 2. Compare the incidence of wrong-patient orders in a "restricted environment" that limits its providers to only one record open at a time to an "unrestricted environment" where users can open a maximum of four records at once. 3. The results of this study will help inform decisions on how to safely implement EHR systems. 4. The results of this study will inform a larger scale health IT implementation research project evaluating the balance between the wrong-patient error risks and potential efficiency gains of having multiple records open at once, with rigorous research methodologies.

Eligibility Criteria

Clinician Participant Inclusion Criteria:

-All clinicians (physicians, nurse practitioners, physician assistants) who placed electronic orders during the study period will be included in the study. (Randomization is at the level of the clinician.)

Clinician Exclusion Criteria:

Clinicians whose workflow requires access to more than one patient record at a time.

Patient Record Inclusion Criteria:

-All inpatient, emergency department, and ambulatory patients for whom electronic orders were placed during the study period will be included in the study.

View full record on ClinicalTrials.gov →

Data sourced from ClinicalTrials.gov (NCT02876588). Outcome figures and adverse-event rates are extracted automatically from the registry's posted results and are provided for clinician reference, not as a substitute for the primary publication.