InformationWeek, July 12, 2012

The researchers at Montefiore Medical Center in New York wanted to find a way to detect wrong-patient orders in their CPOE system. Since clinician reports were unreliable, they looked at a marker for these errors: the retraction of orders within 10 minutes of placement, followed by reorders 10 minutes later. The investigators hypothesized that doctors had placed many of these orders on wrong patients, and it turned out they were right: Interviews with 233 physicians over a four-month period showed that 76% of the original orders had been for the wrong patients.

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