A Proactive Risk Avoidance System Using Failure Mode and Effects Analysis for "Same-Name" Physician Orders

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Background: Of the nearly one million physicians in the United States, only 24% have unique last names. More than 875,000 medical licensees share an exact last name with another colleague. It is rational to conclude that orders written by "same-name" (including similarly named) physicians have the potential to delay or impede the correct medical order implementation or the interpretation of diagnostic results. However, no guidelines are available for addressing same-name physicians within a health care system.

Risk Identification and Proactive Risk Assessment: Proactive identification of this potential risk occurred at a midwest community hospital through the use of patient safety leadership walk-arounds. A team chartered to address the issue proactively used a Failure Mode and Effects Analysis process. The risk of identifying the wrong physician was quantified using risk priority numbers (RPNs) on the basis of the team's assessment of the occurrence, detectibility, and severity of the potential problem. The team developed multiple innovations to reduce the risk. For example, a feature of forced entry within the EMR was implemented—staff entering an order written by a same-name physician were forced to delineate between physicians by using additional identifiers to proceed any further in the EMR. Individualized methods of communicating with all employees and physicians were developed to ensure accurate implementation of innovations.

Postimplementation Results: Development of a structured, objective method for identifying same-name physicians in orders has reduced the potential risks to patient safety, as measured by the change in the RPN from 573 to 275, in less than one year.

Conclusions: Accurate identification of same-name physicians averted a safety risk that has widespread implications across health care settings.

Document Type: Research Article

Publication date: October 1, 2010

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  • Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.

    Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety
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