Department of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.
Department of Pharmacy Practice, MCPHS University, Boston, MA, USA.
J Am Med Inform Assoc. 2018 Jun 1;25(6):709-714. doi: 10.1093/jamia/ocy003.
Electronic prescribing promises to improve the safety and clarity of prescriptions. However, it also can introduce miscommunication between prescribers and pharmacists. There are situations where information that is meant to be sent to pharmacists is not sent to them, which has the potential for dangerous errors.
To examine how frequently prescribers or administrative personnel put information intended for pharmacists in a field not sent to pharmacists, classify the type of information included, and assess the potential harm associated with these missed messages.
DESIGN, SETTING, PARTICIPANTS: Medication record data from our legacy electronic health record were requested for ambulatory care patients seen at an academic medical center from January 1, 2000, to May 31, 2015 (20 123 881 records). From this database, 6 060 272 medication orders met our inclusion criteria. We analyzed a random sample of 10 000 medication orders with internal comments.
Reviewers classified internal comments for intent. Comments intended for pharmacists were also sorted into descriptive categories and analyzed for the potential for patient harm.
We found that 11.7% of the prescriptions in our sample contained comments that were intended to be sent to pharmacists. Many comments contained information about the dose, route, or duration of the prescription (38.0%). Approximately a third of the comments intended for pharmacists contained information that had the potential for significant or severe harm if not communicated.
We found undelivered comments that were clearly intended for pharmacists and contained important information for either pharmacists or patients. This poses a legitimate safety concern, as a portion of comments contained information that could have prevented severe or significant harm.
电子处方有望提高处方的安全性和清晰度。然而，它也可能导致医生和药剂师之间的沟通失误。有些情况下，本应发送给药剂师的信息并未发送给他们，这可能会导致危险的错误。
检查医生或行政人员将原本打算发送给药剂师的信息放入未发送给药剂师的字段中的频率，对所包含信息的类型进行分类，并评估这些遗漏信息可能带来的潜在危害。
设计、地点和参与者：从我们的传统电子健康记录中请求了 2000 年 1 月 1 日至 2015 年 5 月 31 日在学术医疗中心就诊的门诊患者的用药记录数据（20063881 条记录）。从该数据库中，有 6060272 条用药医嘱符合我们的纳入标准。我们分析了随机抽取的 10000 条用药医嘱及其内部评论。
审查员根据意图对内部评论进行分类。原本打算发送给药剂师的评论也被归入描述性类别，并分析其是否可能对患者造成伤害。
我们发现，我们样本中的 11.7%的处方包含了原本打算发送给药剂师的评论。许多评论包含了关于剂量、给药途径或处方持续时间的信息（38.0%）。大约三分之一的原本打算发送给药剂师的评论包含了如果不进行沟通就可能造成重大或严重伤害的信息。
我们发现了一些未送达的评论，这些评论显然是打算发送给药剂师的，并且包含了对药剂师或患者都很重要的信息。这引发了一个合理的安全问题，因为部分评论包含的信息本可以防止严重或重大伤害。
