Increasing Recognition of Wrong-Patient Errors through Improved Interface Design of a Computerized Provider Order Entry System

Wrong-patient errors from inadvertent menu selections while using computerized provider order entry (CPOE) systems could have fatal consequences. This study investigated whether the manipulation of CPOE interface design could improve healthcare providers’ ability to recognize patient selection errors and also decrease the time to error recognition. Using a 2 × 2 design, 120 participants were randomly assigned to one of four groups, interacting with different versions of a simulated CPOE: (1) control–standard version; (2) highlighted selection–the selected patient row was highlighted for 2 s, by blanking the rest of the screen; (3) photo–photographs of patients’ faces were displayed in all screens; (4) combined–with photo and highlighted selection. Each participant navigated through five order scenarios. On the last scenario, an error was simulated by directing the participant to a wrong patient. Recognition rates of the wrong-patient error and times to error recognition were significantly improved for the highlighted selection, photo, and combined groups, relative to the control group. These results suggest that the addition of patient photos and highlighted selection could substantially reduce errors in CPOE systems and other applications.