Study examines incidence of inconsistent communication present with CPOE

Computer Physician Order Entry (CPOE) has been thought to be one method to reduce the number of medication errors occurring at hospitals. Although there are many opportunities for a prescription error to take place when using a CPOE system, a new study attempted to examine the chance of an error occurring due to inconsistencies between the CPOE order and the notes field that allows for a physician to offer his or her own thoughts. The study, published in a recent issue of the Archives of Internal Medicine, found that while these types of errors are not common, they do occur and should be studied more.

The researchers studied CPOE records for four months at a tertiary care facility with the help of four pharmacists. The researchers compared any inconsistencies found between the prescription ordered an the notes in written in the free text field, and then determined that .095% contained inconsistent communication. Of those, 20% could have resulted in serious harm to the patient. The most frequent inconsistency found was dosage amounts.

Although this was a preliminary review, more research is necessary. The authors suggested a better interface for CPOE systems be incorporated as the technology improves.

Has your facility received feedback from those using a CPOE system about the “free text” field and whether it helps or hinders their use of the system?