Inconsistent communication within CPOE poses significant safety risks

A prospective study published in Archives of Internal Medicine demonstrated that despite standardization of data entry within the computerized provider order entry (CPOE) system in a specific healthcare facility, inconsistent communication in orders entered into the CPOE posed a significant safety risk.

Investigators conducted this study at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas. In this healthcare facility, prescription orders are entered exclusively through CPOE; the CPOE system offers structured fields as well as an option to enter free-text comments. The facility requires that pharmacists call the provider if modification of an inconsistency in the order involves a change in administration route, dose, schedule, or drug name, or if comments are unclear. Prescriptions were evaluated between October 1, 2007, and January 31, 2008. The investigators assessed inconsistent communication (involving elements of the structured fields, including drug name, dosage, administration route, schedule, administration time, days supplied, quantity, refills, and duration) through stimulated pharmacy reporting and electronic searches for prescriptions with comments. For the electronic search, the investigators retrieved all prescriptions that contained comments in the free-text field and then randomly selected 500 for manual review. The investigators used a data collection form that captured the type of medication, setting, nature of the inconsistency, and potentially predictive variables (ie, instances in which communication errors may be more likely). The potential for harm was also assessed (no error, inconvenience, very minor harm, minor harm, considerable harm, very serious harm, serious permanent damage, and immediate and inevitable death).

Of the 45 pharmacists in this healthcare system, 33 agreed to participate in the study. During the study period, 55,992 new prescriptions were processed and reviewed by the pharmacists, and 532 (0.95%) were reported by the pharmacists to contain inconsistent communication. Of the 157,055 prescriptions that contained a comment in the free-text window, the researchers chose 500 at random for manual review. After excluding 9 of the prescriptions (written for glucose-motoring supplies), the researchers observed that 26 of the remaining 491 prescriptions (5.3%) contained inconsistent communications, none of which were reported by the pharmacists. Extrapolating this 5.3% error rate to the entire population of prescriptions with free-text comments, the investigators determined that 8,324 of the prescriptions might contain inconsistent communication; after adjusting for a larger sample size including both new and refill prescriptions, they estimated that the overall rate of errors of inconsistent communication would be 1%.

Drug dosage and duration of medication administration for inpatients were the most common inconsistent elements (44.9% and 24.4%, respectively). Orders containing inconsistent communication were most likely to be entered by trainees (59%). Cardiovascular and antihypertensive drugs were the drug classes most often affected by errors (15.8%). When categorized by potential harm to the patient, most errors were classified as an inconvenience (29.4%), but 112 of the errors had the potential to cause moderate-to-severe harm (20.1%). Anticoagulants were associated with the highest risk of causing moderate-to-severe harm (OR=61.9; 95% CI, 10.7–356.9), and high-alert medications had a high potential for causing moderate-to-severe harm (OR=3.43; 95% CI, 1.62–7.27).

The researchers concluded that, despite potential limitations of their study (including limited generalizability, potential under-reporting, and selection bias), these results indicate that “inconsistent communication poses significant risks to safety achieved by CPOE.” They suggested that “improving the usability of the CPOE interface and integrating it with workflow may reduce this risk.”

In a related editorial, David Liebovitz, MD, discussed the potential problems with healthcare information technology, pointing out that “unanticipated adverse consequences of electronic ordering and documentation systems are becoming more widely reported in the literature as experience with these systems increases.” Dr Liebovitz added that the results of this study point out a weakness that is “but 1 example of how technically and culturally primitive we remain in our efforts to leverage EHRs to improve the care of individual patients and populations.”

SourceSingh H, Mani S, Espadas D, Petersen N, Franklin V, Petersen LA. Prescription errors and outcomes related to inconsistent information transmitted through computerized order entry. Arch Intern Med. 2009;169:982–989.

Liebovitz D. Health care information technology: A cloud around the silver lining [editorial]? Arch Intern Med. 2009;169:924–926.