Free-Text Computerized Provider Order Entry Orders Used as Workaround for Communicating Medication Information.

Area of Science:

• Health Informatics
• Patient Safety
• Clinical Communication

Background:

• Electronic health records (EHRs) frequently use free-text computerized provider order entry (CPOE) for medication information.
• Communication of medication details outside structured CPOE orders increases the risk of medication errors.
• A gap exists in understanding the specific medication information communicated via free-text CPOE orders.

Purpose of the Study:

• To identify common medication names and associated risk levels in free-text CPOE orders.
• To determine physician expectations for nurse actions based on free-text CPOE orders.
• To describe inter-hospital variations in these communication patterns.

Main Methods:

• Retrospective analysis of 26,524 free-text CPOE orders.
• Data collected from 6 hospitals in the mid-Atlantic U.S. region.
• Analysis focused on medication names, intended actions, and hospital-specific trends.

Main Results:

• 193 unique medication names were identified in free-text CPOE orders.
• Naloxone, heparin, flumazenil, and dextrose were frequently communicated.
• 22% of orders pertained to discontinuing medications, while 7% related to administering them, with significant hospital variation.

Conclusions:

• The prevalence of medication information in free-text CPOE orders indicates communication challenges.
• Addressing communication gaps for high-risk medications is crucial for reducing medication errors.
• Understanding physician expectations and common medication mentions can improve patient safety.