Do We Need a Safety Pause Before Every Computerized Medication Order?

Computerized provider order entry systems make it easy to enter orders for the wrong patient. Investigators assessed the effects of a safety pause system, in which prescribers were required to confirm the patient's identity after a mandatory 2.5-second delay. The system was implemented during a 4-month study period at five emergency departments in New York City; all used the same electronic medical record system (Allscripts Sunrise).

After implementation, wrong-patient orders were reduced by 30% — from 2.0 to 1.4 per 1000 orders. However, each averted error cost 1.5 hours of physician time (physicians tended to take longer than the minimum of 2.5 seconds to complete the patient verification). Per shift, this added an average of 2.1 minutes o…