News Release

AHRQ grant awarded to study the impact of health IT on patient safety at Montefiore and Einstein and Brigham and Women's Hospital

$300,000 grant will fund research to determine risk of wrong patient electronic errors

Grant and Award Announcement

Albert Einstein College of Medicine

NEW YORK (September 22, 2014) –Montefiore Medical Center, Albert Einstein College of Medicine of Yeshiva University and Brigham and Women's Hospital have received a $300,000 grant from The Agency for Healthcare Research and Quality (AHRQ) to study the impact of health Information Technology (IT) on patient safety.

This research will directly address "wrong patient" electronic orders, an important clinical patient safety issue impacted by health IT. Upon completion of the study, it will be the first time IT leaders have data on the risk of "wrong patient" errors when a varying number of clinical records are opened at once. This information will help determine the best format for their computerized provider order entry (CPOE) systems.

"CPOE systems have been shown to prevent many types of medical errors, but certain types of errors occur frequently in these systems, including placing orders on the wrong patient," said Jason Adelman, M.D., M.S., patient safety officer at Montefiore Medical Center, assistant professor of medicine at Einstein, and principal investigator on the grant. "We propose to do a prospective, observational study that examines the relationship between the number of records open at the time of placing an order and the risk of placing an order on the wrong patient."

The research also will include a two-armed crossover pilot study that evaluates the wrong patient error rate when the system is configured to allow only one record open at a time compared to a system configured to allow a maximum of four records to be open at one time.

A national survey of Chief Medical Information Officers conducted by Montefiore Medical Center in March 2014 previously demonstrated the lack of consensus on the safest number of patient records being opened at once. Of the 91 respondents, 76 had CPOE systems capable of simultaneously displaying multiple patient records. Among these 76 respondents, there was marked heterogeneity in the number of records allowed open by IT leadership, with several hospitals changing their settings after the initial configuration. Some changed their system to allow more records open, while others decided to limit their system to only one record at a time.

This study is made possible by an innovative tool developed at Montefiore. The Retract-and-Reorder tool, which detects orders placed on a patient that are retracted within 10 minutes and then placed by the same clinician on a different patient, detects wrong patient orders that are "near miss" events. This tool will be used to identify the primary outcome measures for both the prospective, observational study as well as the two-armed crossover pilot study.

The grant is part of $4 million funding from the United States Congress to finance AHRQ's support for research on health IT's impact on patient safety.

Additional investigators included from Montefiore-Einstein: Will Southern, M.D., M.S., Matthew Berger, M.D., Paul Meissner, M.S.P.H., and Parsa Mirhaji, M.D., Ph.D.; from Einstein: Clyde Schechter, M.D.; From Brigham and Women's: Gordon Schiff, M.D., David Bates, M.D., Adam Wright, Ph.D and Alice Brandwein, Ph.D.


About Montefiore Medical Center

As the University Hospital and academic medical center for Albert Einstein College of Medicine, Montefiore is renowned for its clinical excellence, scientific discovery and commitment to its community. Recognized among the top hospitals nationally and regionally by U.S. News & World Report, Montefiore provides compassionate, patient- and family-centered care and educates the healthcare professionals of tomorrow. The Children's Hospital at Montefiore is consistently named in U.S. News' "America's Best Children's Hospitals." With four hospitals, 1,512 beds and more than 84,000 annual admissions, Montefiore is an integrated health system seamlessly linked by advanced technology. State-of-the-art primary and specialty care is provided through a network of more than 150 locations across the region, including the largest school health program in the nation and a home health program. Montefiore's partnership with Einstein advances clinical and translational research to accelerate the pace at which new discoveries become the treatments and therapies that benefit patients. The medical center derives its inspiration for excellence from its patients and community, and continues to be on the frontlines of developing innovative approaches to care. For more information please visit and Follow us on Twitter; like us on Facebook; view us on YouTube.

About Albert Einstein College of Medicine of Yeshiva University

Albert Einstein College of Medicine of Yeshiva University is one of the nation's premier centers for research, medical education and clinical investigation. During the 2013-2014 academic year, Einstein is home to 734 M.D. students, 236 Ph.D. students, 106 students in the combined M.D./Ph.D. program, and 353 postdoctoral research fellows. The College of Medicine has more than 2,000 full-time faculty members located on the main campus and at its clinical affiliates. In 2013, Einstein received more than $155 million in awards from the NIH. This includes the funding of major research centers at Einstein in diabetes, cancer, liver disease, and AIDS. Other areas where the College of Medicine is concentrating its efforts include developmental brain research, neuroscience, cardiac disease, and initiatives to reduce and eliminate ethnic and racial health disparities. Its partnership with Montefiore Medical Center, the University Hospital and academic medical center for Einstein, advances clinical and translational research to accelerate the pace at which new discoveries become the treatments and therapies that benefit patients. Through its extensive affiliation network involving Montefiore, Jacobi Medical Center -Einstein's founding hospital, and five other hospital systems in the Bronx, Manhattan, Long Island and Brooklyn, Einstein runs one of the largest residency and fellowship training programs in the medical and dental professions in the United States. For more information, please visit, read our blog, follow us on Twitter, like us on Facebook, and view us on YouTube.

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