Dr. Adelman’s Patient Safety Research Program began with the development of the Wrong-Patient Retract-and-Reorder (RAR) Measure—a valid and reliable method of quantifying the frequency of wrong-patient orders placed in electronic ordering systems. The Wrong-Patient RAR measure was the first automated measure of medical errors and the first Health IT Safety Measure endorsed by the National Quality Forum. The RAR method identifies thousands of near-miss, wrong-patient errors per year in large health systems, enabling researchers to test interventions to prevent this type of error.
The Wrong-Patient RAR measure has been used to evaluate the effectiveness of patient safety interventions in several studies conducted in different electronic health record systems and clinical settings, including in the neonatal intensive care unit (NICU). The measure is the primary outcome measure for three federally funded studies supported by the Agency for Healthcare Research and Quality (R21HS023704, R01HS024945) and the National Institute for Child Health and Human Development (R01HD094793). Additional research is underway to extend the RAR methodology to other types of errors, such as wrong-drug errors, and develop new health IT safety measures (R01HS024538).
Results of Dr. Adelman’s research led to national patient safety guidance, including a recommendation issued by the Office of the National Coordinator for Health Information Technology that healthcare organizations use the Wrong-Patient RAR measure to monitor the frequency of wrong-patient orders. Effective 2019, The Joint Commission will require that hospitals adopt a distinct newborn naming convention that incorporates the mother’s first name, based on studies by Adelman and colleagues.