National Patient Safety Goals (NPSG) (Nursing Care Center / Nursing Care Center)
Two Patient Identifiers - Written Orders/ Computerized Prescriber Orders
Publish | January 01, 0001
Does the two-identifier rule apply to writing orders for treatment? What about computerized prescriber order entry (CPOE) systems?
Yes; the requirement for two identifiers applies to writing orders, including use of CPOE. A common "wrong patient" error is the recording of orders in the wrong patient's record. In most cases, the error is recognized by another caregiver; however, there are a significant number of such cases in which the error is not recognized and the patient receives an inappropriate treatment. Similarly, "wrong patient orders" can be an unintended consequence of using some CPOE systems that do not provide adequate safeguards including at least two identifiers to assure correct patient identification before accepting orders (1).
1. Ross Koppel, PhD; Joshua P. Metlay, MD, PhD; Abigail Cohen, PhD; Brian Abaluck, BS; A. Russell Localio, JD, MPH, MS; Stephen E. Kimmel, MD, MSCE; Brian L. Strom, MD, MPH. Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors. JAMA. 2005;293:1197-1203.
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