Evaluating the Impact of Patient Photographs for Preventing Wrong-Patient Errors

NCT03626766 | Completed Results DMC

• 3 other identifiers: AAAR0080R01HS024713R01HD094793
• Study Type: interventional
• Target: 10,426
• Locations: 1 country
• Sites: 3

Brief Summary

This is a multi-site, 4-arm randomized controlled trial to test the effectiveness of patient photographs displayed in electronic health record (EHR) systems to prevent wrong-patient order errors. The study will be conducted at several academic medical centers that utilize two different EHR systems. Because EHR systems have different functionality for displaying patient photographs, two different study designs will be employed. In Allscripts EHR, a 2-arm randomized trial will be conducted in which providers are randomized to view order verification alerts with versus without patient photographs when placing electronic orders. In Epic EHR, a 2x2 factorial trial will be conducted in which providers are randomized to one of four conditions: 1) no photograph; 2) photograph displayed in the banner only; 3) photograph displayed in a verification alert only; or 4) photograph displayed in the banner and verification alert. The main hypothesis of this study is that displaying patient photographs in the EHR will significantly reduce the frequency of wrong-patient order errors, providing health systems with the evidence needed to adopt this safety practice.

Conditions

Medical Errors; Electronic Medical Records

Keywords

Allscripts; Epic; Electronic Health Record (EHR); Electronic orders

Outcome Measures

Primary Outcomes (1)

• Number of Order Sessions With at Least One Retract-and-Reorder (RAR) Event as Identified by the Wrong-Patient Retract-and-Reorder (RAR) Measure.

  Using the Wrong-Patient (WP) Retract-and-Reorder measure, the outcome was WP order sessions, defined as series of orders placed by 1 clinician for 1 patient that included ≥1 WP order. The Wrong-Patient Retract-and-Reorder (RAR) measure is an automated, validated, and reliable measure endorsed by the National Quality Forum (NQF #2723). The RAR measure identifies orders placed for a patient that are retracted within 10 minutes, and then placed by the same provider for a different patient within the next 10 minutes. These are near-miss errors, self-caught by the provider before they reach the patient and cause harm.

  2 years

Study Arms (4)

Photo in Verification Alert

ACTIVE COMPARATOR

Patient photo displayed in a patient ID verification alert when placing electronic orders in the electronic health record.

Behavioral: Photo in Verification Alert

Photo in Banner

ACTIVE COMPARATOR

Patient photo displayed in the banner (at the top of the screen).

Behavioral: Photo in Banner

Photo in Banner and Verification Alert

ACTIVE COMPARATOR

Patient photograph displayed in the banner (at the top of the screen) AND patient photo displayed in a verification alert when placing electronic orders.

Behavioral: Photo in Banner and Verification Alert

No Photo

NO INTERVENTION

No patient photographs displayed in the electronic health record.

Interventions

Photo in Verification Alert BEHAVIORAL

Patient photograph displayed in a patient ID verification alert when placing electronic orders in the electronic health record.

Photo in Verification Alert

Photo in Banner BEHAVIORAL

Patient photograph will be displayed in the banner at the top of the screen in the electronic health record.

Photo in Banner

Photo in Banner and Verification Alert BEHAVIORAL

Patient photograph will be displayed in the banner at the top of the screen in the electronic health record AND patient photograph displayed in a patient ID verification alert when placing electronic orders in the electronic health record.

Photo in Banner and Verification Alert

Eligibility Criteria

• Sex: all
• Healthy Volunteers: No
• Age Groups: Child (0-17), Adult (18-64), Older Adult (65+)

You may qualify if:

• All patients for whom an order was placed in the study period.
• All providers with the authority to place electronic orders and who placed electronic orders during the study period.

You may not qualify if:

• None

Sponsors & Collaborators

• Columbia University: lead
• Agency for Healthcare Research and Quality (AHRQ): collaborator
• Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD): collaborator
• Montefiore Medical Center: collaborator
• Brigham and Women's Hospital: collaborator

Study Sites (3)

Johns Hopkins Medicine

Baltimore, Maryland, 21287, United States

Location

Columbia University Irving Medical Center / NewYork-Presbyterian Hospital

New York, New York, 10032, United States

Location

Weill Cornell Medical Center - Weill Cornell Medicine

New York, New York, 10065, United States

Location

Related Publications (1)

• Adelman JS, Kalkut GE, Schechter CB, Weiss JM, Berger MA, Reissman SH, Cohen HW, Lorenzen SJ, Burack DA, Southern WN. Understanding and preventing wrong-patient electronic orders: a randomized controlled trial. J Am Med Inform Assoc. 2013 Mar-Apr;20(2):305-10. doi: 10.1136/amiajnl-2012-001055. Epub 2012 Jun 29.

  PMID: 22753810 BACKGROUND

Results Point of Contact

• Title: Dr. Anthony Lin
• Organization: Columbia University

akl17@cumc.columbia.edu

(917) 628-6522

Study Officials

• Jason S. Adelman, MD, MS

  Columbia University

  PRINCIPAL INVESTIGATOR

Publication Agreements

• PI is Sponsor Employee: Yes

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: NONE
• Purpose: HEALTH SERVICES RESEARCH
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: August 6, 2018
• First Posted: August 13, 2018
• Study Start: November 16, 2021
• Primary Completion: October 1, 2023
• Study Completion: April 1, 2024
• Last Updated: March 17, 2025
• Results First Posted: March 17, 2025

Record last verified: 2025-02

Data Sharing

• IPD Sharing: Will not share

Locations

US (3)