Our Impact

Advancing Patient Safety Research, Health Policy, and Guidelines

The Wrong-Patient RAR measure uses an electronic query to detect orders placed for a patient that are cancelled within 10 minutes, and then reordered by the same provider for a different patient within the next 10 minutes.

The Wrong-Patient Retract-and-Reorder Measure was the first Health IT Safety Measure endorsed by National Quality Forum (NQF Measure #2723). WP-RAR uses an electronic query to detect orders placed for a patient that are retracted within 10 minutes, and then reordered by the same provider for a different patient within the next 10 minutes. Real-time interviews demonstrated that 76% of RAR events identified by the measure were confirmed near-miss wrong-patient orders. Results led to National Patient Safety Recommendations in the Patient Identification SAFER Guide issued by ONC.

Nondistinct Naming Convention
Distinct Naming Convention
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Temporary names are made more distinct by incorporating the mother’s first name into the newborn’s first name. These results had far-reaching impact.

The Joint Commission and the Children’s Hospital Association issued recommendations that hospitals adopt the distinct naming convention for newborns and the leading EHR vendor Epic adopted the distinct naming convention as its standard. In addition, the Joint Commission released a requirement, effective January 2019, that all hospitals use the distinct naming convention for identifying newborns as part of its National Patient Safety Goals.

The RAR Measure was used to test verification alerts in a 3-arm randomized controlled trial at a large hospital system. Both the ID-verify alert and the ID-reentry function significantly reduced the odds of placing a wrong-patient order by 16% and 41% respectively compared to no intervention. The ONC Patient Identification SAFER Guide recommends that providers enter patients’ initials prior to signing an order in the EHR based on results of this study.