46: Wrong patient orders in obstetrics: An unrecognized patient safety risk

Abstract

Wrong-patient orders represent a well-documented patient safety risk. Obstetric patients possess similarities that may increase the risk of wrong-patient orders, including age, gender, and diagnoses. Surveillance of electronic clinical data is an effective approach to identify wrong-patient orders by assessing temporality of order placement, discontinuation, and re-entry using the NQF-endorsed Wrong-Patient Retract-and-Reorder measure (RAR). We sought to identify and describe the previously unexamined issue of wrong-patient orders in obstetrics. The study was conducted in a large inner-city integrated health system. The primary outcome was near-miss, wrong-patient orders identified using RAR. The RAR measure uses an electronic query to detect RAR events, orders placed for patient A, canceled by same clinician within 10 minutes, and reordered by same clinician for patient B within next 10 minutes. All electronic orders placed for women age ≥18 years receiving care in obstetric units were extracted retrospectively from the health system data warehouse from January 1, 2018 to December 31, 2018. RAR event rates were calculated overall, and by subgroups defined by clinician type, order type, order timing, and medication type, using the order as the unit of analysis. Rates are reported as RAR events per 100,000 orders. Of 1,058,429 orders placed for 16,691 OB patients, 516 RAR events were identified for a rate of 48.8 per 100,000 orders. RAR rates by clinician type, order type, and order timing are presented in Table 1. Medication errors accounted for half of RAR events, including uterotonics, tocolytics, antibiotics, and antihypertensives (Table 2). In obstetrics, wrong-patient orders occur in commonly used and high-risk medications, among house staff, and during night shifts. Systems strategies shown to decrease these events in other high-risk specialties should be explored in obstetrics in efforts to make maternity care safer.View Large Image Figure ViewerDownload Hi-res image Download (PPT)