Picture this scenario: An ED doc treating a lung cancer patient with IV hydration is also caring for a patient who was in a car accident. He accidentally enters an order for a paralytic and sedative into the cancer patient’s record. The cancer patient’s regular nurse is on break. The covering nurse sees the orders and administers the drugs. The patient goes into respiratory arrest and dies.

This situation, as described in a 2011 Institute for Safe Medication Practices brief, highlights one of the challenges facing the field: Computerized provider order entry and other applications are designed to improve patient safety, but they must be part of a systematic approach to reduce errors.

Now, not all wrong-patient orders actually reach the patient and cause harm. Many are caught ahead of time and clinicians make the corrections in time. Another example in the ISMP brief describes how a pharmacist realized that he was entering an order for Franklin Hope in Hope Franklin’s record.

For the second time in recent years, patient safety experts at Montefiore Medical Center and Albert Einstein College of Medicine are embarking on a study to assess how clinicians interact with CPOE systems with the aim of determining if there are ways to reduce near misses and actual errors. Earlier this week, the researchers announced that they had received a $300,000 AHRQ grant to see how clinicians behave in a system that only permits one patient record to be opened at a time versus one that allows four. (Brigham and Women’s Hospital also will be part of the study). Two years ago, the researchers assessed whether various interventions could minimize wrong-patient orders. They found that forcing clinicians to verify and re-enter orders improved behavior.

“Not much is known about exactly how big of a problem this is,” says Jason Adelman, M.D., patient safety officer at Montefiore, assistant professor of medicine at Einstein, and principal investigator on the grant. “The data we have is sporadic and some of it is unreliable. If you speak to CMIOs and patient safety officers, though, you will hear that it is a common problem. People don’t want to report it, because it is an embarrassing mistake.”

In their 2012 study, Adelman and his team looked at 9 million electronic orders placed by 6,147 providers at Montefiore in 2009. They found that 1,388 providers retracted and reordered 6,885 electronic orders, usually within one minute. Granted, that’s a small piece of 9 million, but try telling that to the grieving child whose mom might have just been given the wrong medication.

The Montefiore studies are part of a broader effort by AHRQ to assess the impact of health IT on patient safety. As the push to digitize health care accelerates, so, too, should our efforts to make sure we are doing things in a thoughtful manner.

“Health IT can prevent a lot of errors, but it can also facilitate them,” Adelman said. “We need to maximize the benefits of computers while minimizing the risks.”