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A Simple Solution to a Serious Medical Error

A 2009 quality-improvement program conducted at Children's Hospital in Colorago identified misplaced orders as the second most common reason why care is provided to the wrong patient. Misplaced orders have been decreased as a result of the program, dropping from 12 incidents in 2010 to 3 incidents one year later.

The quality-improvement plan involved a change in the computer system that would attach a digital photo to the patients' records. Before entering a test or treatment onto a patient's form, the computer required a verification that brought up the patient's photo. This simple step greatly reduced the number of misplaced orders and "near misses" involving incorrect orders that were caught before procedures were performed.

No comprehensive study has been conducted to determine the frequency of misplaced orders. Despite the relatively small number of incidents of this form of medical error at Children's Hospital, the chief quality officer at the Colorado facility said that the total number would add up when gathered from all hospitals in the United States. It is possible these situations could be eliminated, or at least greatly reduced, by requiring a doctor to look at a screen with a picture of the patient before entering in the recommended treatment. The solution would be feasible for most hospitals to facilitate and inexpensive when compared to many other suggested safety precautions.

Patients should feel confident that the treatment they receive from doctors is in their best interests. Every medication and procedure should be intended to improve the patient's situation. If the inclusion of a photo in a patient's file would decrease the dangerous problem of misplaced orders, more hospitals should consider making the change.

Source: Chicago Tribune, "Can patient photos help cut medical errors?," by Amy Norton, 4 June 2012

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