From the Emory University School of Medicine, Atlanta, Georgia.
Robert H. Smith School of Business, University of Maryland, College Park, Maryland.
J Patient Saf. 2022 Aug 1;18(5):430-434. doi: 10.1097/PTS.0000000000000948. Epub 2021 Dec 17.
Medication information is frequently communicated via free-text computerized provider order entry (CPOE) orders in electronic health records. When such information is transmitted separately from a structured CPOE medication order, there is a significant risk of medication error. Although prior studies have described the frequency of using free-text CPOE orders for communicating medication information, there is a gap in understanding the nature of the medication information contained in the free-text CPOE orders. The aims of this study are to (1) identify the most common medication names communicated in free-text CPOE orders and their risk levels and (2) identify what actions physicians expect that nurses will complete when they place free-text CPOE orders, and (3) describe differences in these patterns across hospitals.
This study was a retrospective analysis of a sample of 26,524 free-text CPOE orders from 6 hospitals in the mid-Atlantic U.S. region.
Free-text CPOE orders contained in the sample mentioned 193 medication names. Free-text CPOE orders were used frequently to communicate information about naloxone, heparin, flumazenil, and dextrose. Twenty-two percent of the free-text CPOE orders related to discontinuing medication(s), whereas 7% of the free-text CPOE orders relate to giving medication(s). There was high variation across hospitals both in the percentage of free-text CPOE orders mentioning medication information and in the proportion of those that referred to high-risk medications.
The prevalence of medication information in free-text CPOE orders may suggest specific communication challenges in respect to urgency, uncertainty, planning, and other aspects of communication and clinical needs. Understanding and addressing communication challenges around commonly mentioned medication names and actions, especially those that are high risk, can help reduce the risk of medication errors.
药物信息经常通过电子病历中的计算机化医嘱录入（CPOE）中的自由文本医嘱传达。当此类信息与结构化 CPOE 药物医嘱分开传输时，存在药物错误的重大风险。尽管先前的研究已经描述了使用自由文本 CPOE 医嘱传达药物信息的频率，但对于自由文本 CPOE 医嘱中包含的药物信息的性质仍存在理解上的差距。本研究的目的是：（1）确定在自由文本 CPOE 医嘱中传达的最常见药物名称及其风险级别；（2）确定医生期望护士在下达自由文本 CPOE 医嘱时完成的操作；（3）描述这些模式在不同医院之间的差异。
本研究是对美国中大西洋地区 6 家医院的 26524 份自由文本 CPOE 医嘱进行的回顾性分析。
样本中的自由文本 CPOE 医嘱中提到了 193 种药物名称。自由文本 CPOE 医嘱经常用于传达纳洛酮、肝素、氟马西尼和葡萄糖的信息。22%的自由文本 CPOE 医嘱与停止用药有关，而 7%的自由文本 CPOE 医嘱与用药有关。各医院之间在提到药物信息的自由文本 CPOE 医嘱的百分比以及提到高风险药物的自由文本 CPOE 医嘱的比例方面存在很大差异。
自由文本 CPOE 医嘱中药物信息的普遍性可能表明在紧急情况、不确定性、计划和其他沟通方面存在特定的沟通挑战以及临床需求。了解和解决常见药物名称和操作方面的沟通挑战，特别是那些高风险的药物，有助于降低药物错误的风险。
