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A Prospective Study

Hardeep Singh, MD, MPH; Shrinidi Mani, BA; Donna Espadas, BS; Nancy Petersen, PhD; Veronica Franklin, RPh; Laura A. Petersen, MD, MPH

Arch Intern Med. 2009;169(10):982-989.

Background  Although several types of computerized provider order entry (CPOE)-related errors may occur, errors related to inconsistent information within the same prescription (ie, mismatch between the structured template and the associated free-text field) have not been described, to our knowledge. We determined the nature and frequency of such errors and identified their potential predictive variables.

Methods  In this prospective study, we enrolled pharmacists to report prescriptions containing inconsistent communication over a 4-month period at a tertiary care facility. We also electronically retrieved all prescriptions written during the study period containing any comments in the free-text field and then randomly selected 500 for manual review to determine inconsistencies between free-text and structured fields. Of these, prescriptions without inconsistencies were categorized as controls. Data on potentially predictive variables from reported and unreported errors and controls were collected. For all inconsistencies, we determined their nature (eg, drug dosage or administration schedule) and potential harm and used multivariate logistic regression models to identify factors associated with errors and harm.

Results  Of 55 992 new prescriptions, 532 (0.95%) were reported to contain inconsistent communication, a rate comparable to that obtained from the unreported group. Drug dosage was the most common inconsistent element among both groups. Certain medications were more likely associated with errors, as was the inpatient setting (odds ratio, 3.30; 95% confidence interval, 2.18-5.00) and surgical subspecialty (odds ratio, 2.45; 95% confidence interval, 1.57-3.82). About 20% of errors could have resulted in moderate to severe harm, for which significant independent predictors were found.

Conclusions  Despite standardization of data entry, inconsistent communication in CPOE poses a significant risk to safety. Improving the usability of the CPOE interface and integrating it with workflow may reduce this risk.

Author Affiliations: Houston Veterans Affairs Health Services Research and Development (VA HSR&D) Center of Excellence and The Center of Inquiry to Improve Outpatient Safety Through Effective Electronic Communication (Drs Singh, N. Petersen, and L. A. Petersen and Mss Mani and Espadas), and the Section of Pharmacy (Ms Franklin), Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas (Drs Singh, N. Petersen, and L. A. Petersen).

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