Department of Pediatrics, Emory University, School of Medicine, Atlanta, Georgia, United States.
MedStar Health National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, District of Columbia, United States.
Appl Clin Inform. 2021 May;12(3):484-494. doi: 10.1055/s-0041-1731002. Epub 2021 Jun 2.
The aim of this study was to investigate (1) why ordering clinicians use free-text orders to communicate medication information; (2) what risks physicians and nurses perceive when free-text orders are used for communicating medication information; and (3) how electronic health records (EHRs) could be improved to encourage the safe communication of medication information.
We performed semi-structured, scenario-based interviews with eight physicians and eight nurses. Interview responses were analyzed and grouped into common themes.
Participants described eight reasons why clinicians use free-text medication orders, five risks relating to the use of free-text medication orders, and five recommendations for improving EHR medication-related communication. Poor usability, including reduced efficiency and limited functionality associated with structured order entry, was the primary reason clinicians used free-text orders to communicate medication information. Common risks to using free-text orders for medication communication included the increased likelihood of missing orders and the increased workload on nurses responsible for executing orders.
Clinicians' use of free-text orders is primarily due to limitations in the current structured order entry design. To encourage the safe communication of medication information between clinicians, the EHR's structured order entry must be redesigned to support clinicians' cognitive and workflow needs that are currently being addressed via the use of free-text orders.
Clinicians' use of free-text orders as a workaround to insufficient structured order entry can create unintended patient safety risks. Thoughtful solutions designed to address these workarounds can improve the medication ordering process and the subsequent medication administration process.
本研究旨在探讨：(1) 医嘱录入员为何使用自由文本医嘱来传达药物信息；(2) 医生和护士在使用自由文本医嘱传达药物信息时认为存在哪些风险；以及(3) 如何改进电子健康记录（EHR）以鼓励安全传达药物信息。
我们对 8 名医生和 8 名护士进行了半结构化、基于场景的访谈。对访谈回复进行了分析和分组，归纳出常见主题。
参与者描述了医嘱录入员使用自由文本医嘱的 8 个原因、与使用自由文本医嘱相关的 5 个风险，以及 5 个改进 EHR 药物相关沟通的建议。结构医嘱录入的可用性差，包括效率降低和功能有限，是医嘱录入员使用自由文本医嘱传达药物信息的主要原因。使用自由文本医嘱传达药物信息的常见风险包括医嘱漏记的可能性增加，以及负责执行医嘱的护士的工作量增加。
医嘱录入员使用自由文本医嘱主要是由于当前结构医嘱录入设计的局限性。为了鼓励医嘱录入员之间安全传达药物信息，必须重新设计 EHR 的结构化医嘱录入，以满足当前通过使用自由文本医嘱来解决的医嘱录入员的认知和工作流程需求。
医嘱录入员将自由文本医嘱作为对结构医嘱录入不足的一种补救措施，可能会带来意想不到的患者安全风险。针对这些补救措施设计的深思熟虑的解决方案可以改进药物医嘱录入过程和随后的药物管理过程。
