Trial Outcomes & Findings for Evaluating the Impact of Patient Photographs for Preventing Wrong-Patient Errors (NCT NCT03626766)

Results Overview

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.

Recruitment status

COMPLETED

Study phase

NA

Target enrollment

10426 participants

Primary outcome timeframe

2 years

Results posted on

2025-03-17

Participant Flow

Participant milestones

Participant milestones
Measure	Photo in Verification Alert Patient photo displayed in a patient ID verification alert when placing electronic orders in the electronic health record. Photo in Verification Alert: Patient photograph displayed in a patient ID verification alert when placing electronic orders in the electronic health record.	Photo in Banner Patient photo displayed in the banner (at the top of the screen). Photo in Banner: Patient photograph will be displayed in the banner at the top of the screen in the electronic health record.	Photo in Banner and Verification Alert Patient photograph displayed in the banner (at the top of the screen) AND patient photo displayed in a verification alert when placing electronic orders. Photo in Banner and Verification Alert: 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.	No Photo No patient photographs displayed in the electronic health record.
Overall Study STARTED	2610	2608	2602	2606
Overall Study COMPLETED	2171	2202	2196	2199
Overall Study NOT COMPLETED	439	406	406	407

Reasons for withdrawal

Withdrawal data not reported

Baseline Characteristics

Sex and gender were not collected from any participant.

Baseline characteristics by cohort

Baseline characteristics by cohort
Measure	Photo in Verification Alert n=2171 Participants Patient photo displayed in a patient ID verification alert when placing electronic orders in the electronic health record. Photo in Verification Alert: Patient photograph displayed in a patient ID verification alert when placing electronic orders in the electronic health record.	Photo in Banner n=2202 Participants Patient photo displayed in the banner (at the top of the screen). Photo in Banner: Patient photograph will be displayed in the banner at the top of the screen in the electronic health record.	Photo in Banner and Verification Alert n=2196 Participants Patient photograph displayed in the banner (at the top of the screen) AND patient photo displayed in a verification alert when placing electronic orders. Photo in Banner and Verification Alert: 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.	No Photo n=2199 Participants No patient photographs displayed in the electronic health record.	Total n=8768 Participants Total of all reporting groups
Age, Customized >18 years	2171 Participants n=2171 Participants	2202 Participants n=2202 Participants	2196 Participants n=2196 Participants	2199 Participants n=2199 Participants	8768 Participants n=8768 Participants
Sex: Female, Male Female	—	—	—	—	0 Participants Sex and gender were not collected from any participant.
Sex: Female, Male Male	—	—	—	—	0 Participants Sex and gender were not collected from any participant.
Race and Ethnicity Not Collected	—	—	—	—	0 Participants Race and Ethnicity were not collected from any participant.
Region of Enrollment United States	2171 Participants n=2171 Participants	2202 Participants n=2202 Participants	2196 Participants n=2196 Participants	2199 Participants n=2199 Participants	8768 Participants n=8768 Participants

PRIMARY outcome

Timeframe: 2 years

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.

Outcome measures

Outcome measures
Measure	Photo in Verification Alert n=3948077 order sessions Patient photo displayed in a patient ID verification alert when placing electronic orders in the electronic health record. Photo in Verification Alert: Patient photograph displayed in a patient ID verification alert when placing electronic orders in the electronic health record.	Photo in Banner n=3958269 order sessions Patient photo displayed in the banner (at the top of the screen). Photo in Banner: Patient photograph will be displayed in the banner at the top of the screen in the electronic health record.	Photo in Banner and Verification Alert n=4028011 order sessions Patient photograph displayed in the banner (at the top of the screen) AND patient photo displayed in a verification alert when placing electronic orders. Photo in Banner and Verification Alert: 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.	No Photo n=4007833 order sessions No patient photographs displayed in the electronic health record.
Number of Order Sessions With at Least One Retract-and-Reorder (RAR) Event as Identified by the Wrong-Patient Retract-and-Reorder (RAR) Measure.	5587 WP Order Sessions	5836 WP Order Sessions	5598 WP Order Sessions	6279 WP Order Sessions

Adverse Events

Photo in Verification Alert

Serious events: 0 serious events

Other events: 0 other events

Deaths: 0 deaths

Photo in Banner

Serious events: 0 serious events

Other events: 0 other events

Deaths: 0 deaths

Photo in Banner and Verification Alert

Serious events: 0 serious events

Other events: 0 other events

Deaths: 0 deaths

No Photo

Serious events: 0 serious events

Other events: 0 other events

Deaths: 0 deaths

Serious adverse events

Adverse event data not reported

Other adverse events

Adverse event data not reported

Additional Information

Dr. Anthony Lin

Columbia University

Phone: (917) 628-6522

Email: [email protected]

Results disclosure agreements

Principal investigator is a sponsor employee
Publication restrictions are in place