"I meant that med for Baylee not Bailey!": a mixed method study to identify incidence and risk factors for CPOE patient misidentification.

Computerized physician order entry (CPOE) systems can create unintended consequences. These include medication errors and adverse drug events. We look at a less understood error; patient misidentification. First, two email surveys were used to establish potential risk factors for this error. Next, an automated detection trigger was designed and validated with inpatient medication orders at a large pediatric hospital. The incidence was 0.064% per medication ordered. Finally, a case-control study identified the following as significant risk factors on multivariate analysis: patient age, last name spelling, bed proximity, medical service, time/date of order, and ordering intensity. These results can be used to improve patient safety by increasing awareness of high risk situations and guiding future research.