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Reasons for computerised provider order entry (CPOE)-based inpatient medication ordering errors: an observational study of voided orders
  1. Joanna Abraham1,
  2. Thomas G Kannampallil2,
  3. Alan Jarman1,
  4. Shivy Sharma1,
  5. Christine Rash3,
  6. Gordon Schiff4,
  7. William Galanter3,5,6
  1. 1Department Biomedical and Health Information Sciences, University of Illinois, Chicago, Illinois, USA
  2. 2Department of Family Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
  3. 3Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, USA
  4. 4Department of General Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
  5. 5Department of Medicine, University of Illinois, Chicago, Illinois, USA
  6. 6Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL, USA
  1. Correspondence to Dr Joanna Abraham, Department of Biomedical and Health Information Sciences, University of Illinois, 1919 W Taylor Street, Chicago, Illinois 60612,USA; abrahamj{at}uic.edu

Abstract

Objective Medication voiding is a computerised provider order entry (CPOE)-based discontinuation mechanism that allows clinicians to identify erroneous medication orders. We investigated the accuracy of voiding as an indicator of clinician identification and interception of a medication ordering error, and investigated reasons and root contributors for medication ordering errors.

Method Using voided orders identified with a void alert, we conducted interviews with ordering and voiding clinicians, followed by patient chart reviews. A structured coding framework was used to qualitatively analyse the reasons for medication ordering errors. We also compared clinician-CPOE-selected (at time of voiding), clinician-reported (interview) and chart review-based reasons for voiding.

Results We conducted follow-up interviews on 101 voided orders. The positive predictive value (PPV) of voided orders that were medication ordering errors was 93.1% (95% CI 88.1% to 98.1%, n=94). Using chart review-based reasons as the gold standard, we found that clinician-CPOE-selected reasons were less reflective (PPV=70.2%, 95% CI 61.0% to 79.4%) than clinician-reported (interview) (PPV=86.1%, 95%CI 78.2% to 94.1%) reasons for medication ordering errors. Duplicate (n=44) and improperly composed (n=41) ordering errors were common, often caused by predefined order sets and data entry issues. A striking finding was the use of intentional violations as a mechanism to notify and seek ordering assistance from pharmacy service. Nearly half of the medication ordering errors were voided by pharmacists.

Discussion We demonstrated that voided orders effectively captured medication ordering errors. The mismatch between clinician-CPOE-selected and the chart review-based reasons for error emphasises the need for developing standardised operational descriptions for medication ordering errors. Such standardisation can help in accurately identifying, tracking, managing and sharing erroneous orders and their root contributors between healthcare institutions, and with patient safety organisations.

  • Medication Safety
  • Patient Safety
  • Qualitative Research

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Footnotes

  • Contributors JA, TGK and WG conceptualised and designed the study. JA, TGK, WG, SS and AJ collected the data. JA, TGK, WG, SS, CR, and AJ were involved in the organisation and analysis of data. JA, TGK, WG and GS were involved in interpreting the results. All authors were involved critically reviewing, revising and finalising the manuscript.

  • Funding This study was supported by a pilot grant fundedby the College of Applied Health Sciences at the University of Illinois atChicago

  • Competing interests None declared.

  • Patient consent No patients were recruited for this study. Interviews were conducted with consented clinicians only.

  • Ethics approval University of Illinois at Chicago Office for the Protection of Research Subjects.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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