A recent study suggests new moms and their babies may be at higher risk for receiving medical care intended for another patient.
Electronic health records provide efficiencies, but also have challenges—especially in busy surgical settings like an emergency department or obstetric unit. New research published in Obstetrics and Gynecology found that erroneous medical orders are placed more often on obstetrical floors than other types of medical—surgical units.
This study looked at data from a large New York health system between January 1, 2016, and December 31, 2018. In that time, 1,329,463 orders were placed with 676,643 of those orders placed on obstetric units.
Researchers evaluated for patient medical orders that were “wrong-patient retract and reorder” events. A retract and reorder event occurs when a medical order (or orders) is created for one patient and then canceled by the clinician within 10 minutes, with a subsequent order going to a different patient within ten minutes. Essentially, the healthcare provider can retract the initial medical order made by mistake, and create a reorder going to the correct patient.
The rate of wrong-patient orders in obstetrical units was approximately 80 mistaken orders per 100,000 orders. For a non-obstetric medical—surgical unit, there were about 43 wrong-patient orders per 100,000 orders. Because wrong-patient orders usually involve drugs, undetected medication errors can cause serious injury when given to the wrong patient. Other wrong-patient orders include nursing orders, lab tests, and imaging tests.
Because all patients admitted to an obstetrical unit have a common diagnosis—pregnancy and childbirth—it may be easier to confuse identities and even medications given to newborns if there is confusion between the name of the mother and her baby. As well, the patients in an OB unit are generally around a similar age and all female.
Suggestions to minimize the risk to new moms and their babies include a culture of calmness and safety when creating and managing orders, creating a time-out when creating orders, and strengthening protocols around nursing hand-offs. EHRs are a useful tool when handled correctly, but can quickly create confusion when used improperly or by poorly trained staff. Modifications to EHRs and better staff training can help decrease confusion with placing orders.
All women and their babies deserve a healthy start. New mothers expect they can trust their nurses and caregivers. If you or your baby suffer an injury at birth, reach out to our law firm.
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