Prescription errors and outcomes related to inconsistent information transmitted through computerized order entry: a...

Area of Science:

• Health Informatics
• Patient Safety
• Clinical Pharmacy

Background:

• Computerized provider order entry (CPOE) systems aim to improve medication safety.
• Errors can arise from inconsistencies between structured data fields and free-text notes within CPOE prescriptions.
• This type of CPOE error has not been previously described.

Purpose of the Study:

• To determine the nature and frequency of CPOE prescription errors caused by inconsistent information.
• To identify variables that predict these errors and their potential harm.

Main Methods:

• Prospective study involving pharmacists reporting inconsistent prescriptions over 4 months.
• Manual review of 500 randomly selected CPOE prescriptions with free-text fields.
• Analysis of potential predictive variables and logistic regression to identify error predictors.

Main Results:

• 0.95% of new prescriptions contained inconsistent communication.
• Drug dosage was the most frequent inconsistency.
• Inpatient setting and surgical subspecialties were associated with higher error rates; 20% of errors could cause moderate to severe harm.

Conclusions:

• Inconsistent communication within CPOE systems presents a substantial patient safety risk.
• Improving CPOE interface usability and workflow integration is recommended to mitigate these risks.