A Proactive Risk Avoidance System Using Failure Mode and Effects Analysis for “Same-Name” Physician Orders

Abstract

Of the nearly one million physicians in the United States, only 24% have unique last names. More than 875,000 medical licensees share an exact last name with another colleague. It is rational to conclude that orders written by "same-name" (including similarly named) physicians have the potential to delay or impede the correct medical order implementation or the interpretation of diagnostic results. However, no guidelines are available for addressing same-name physicians within a health care system. Proactive identification of this potential risk occurred at a midwest community hospital through the use of patient safety leadership walk-arounds. A team chartered to address the issue proactively used a Failure Mode and Effects Analysis process. The risk of identifying the wrong physician was quantified using risk priority numbers (RPNs) on the basis of the team's assessment of the occurrence, detectibility, and severity of the potential problem. The team developed multiple innovations to reduce the risk. For example, a feature of forced entry within the EMR was implemented--staff entering an order written by a same-name physician were forced to delineate between physicians by using additional identifiers to proceed any further in the EMR. Individualized methods of communicating with all employees and physicians were developed to ensure accurate implementation of innovations. Development of a structured, objective method for identifying same-name physicians in orders has reduced the potential risks to patient safety, as measured by the change in the RPN from 573 to 275, in less than one year. Accurate identification of same-name physicians averted a safety risk that has widespread implications across health care settings.