Elsevier

The Journal of Pediatrics

Volume 149, Issue 4, October 2006, Pages 461-467.e1
The Journal of Pediatrics

Original article
Inpatient verbal orders and the impact of computerized provider order entry

https://doi.org/10.1016/j.jpeds.2006.05.038Get rights and content

Objective

To describe the characteristics of verbal orders at a tertiary care children’s hospital.

Study design

Between August 2003 and January 2004, the computerized provider order entry (CPOE) system was evaluated for the characteristics of verbal orders. The rate of total orders represented by verbal orders and the rate of unsigned verbal orders were examined before, during, and after CPOE implementation.

Results

After CPOE implementation, a mean of 19,996 ± 521 orders were generated weekly; of these, 2094 ± 65 (10%) were verbal orders. The greatest rates of verbal orders were from psychiatry (74%) units and involved medication orders (38%; 790/2094). The greatest rates of medication verbal orders were psychotherapeutics (24%; 662/2697). Medical physicians had a larger rate of verbal orders than surgical physicians. The rates of verbal orders and unsigned verbal orders were reduced from 23% and 43% before CPOE implementation to 10% and 9% after implementation, respectively.

Conclusions

Medication orders from physicians to nurses are the primary source of verbal orders in this tertiary care children’s hospital. CPOE implementation significantly affected both verbal orders and the rate of unsigned verbal orders. This type of data is important for institutions aiming to decrease verbal orders and associated medical errors.

Section snippets

Institutional Background

CCHMC is a 423-bed tertiary care children’s hospital with more than 760,000 patient visits each year. The hospital serves the southern Ohio, northern Kentucky, western West Virginia, and eastern Indiana region.

CPOE system

The CPOE application is part of a larger Integrating Clinical Information System (ICIS), whose core applications include a web-based portal, CPOE, clinical documentation, and a data repository (INVISION; Siemens Medical Solutions, Malvern, PA). ICIS is a proprietary system that has been

Results

Data from electronic order audits conducted from August 2003 to January 2004 (the stable CPOE period) were analyzed. During this period, a mean of 19,996 ± 521 orders were generated weekly; 2094 ± 65 (10%) of these were verbal orders. The highest rates of verbal orders were from the psychiatry (74%; 578/784), cardiac intensive care (13%; 162/1248), and surgical short-stay (6%; 33/557) units. The lowest rates of verbal orders were from pediatric intensive care (2%; 53/2777), clinical research

Patient Safety

Verbal orders have become a target for medical institutions in efforts to improve patient safety practices and prevent medication errors. Institutions use recommendations to promulgate guidelines for preventing verbal orders; however, often these recommendations are not evidence-based. One of the only studies examining the use of verbal orders and medication errors reported a decreased risk of errors with verbal orders.15 However, errors were generated by a pharmacy review or an incident report

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      However, as seen in certain circumstances, the context of CPOE use compelled the providers to bypass it. Verbal orders then were still frequently used, although it is supposed that the implementation of CPOE systems should decrease their number significantly [24,25]. The fact that these verbal orders are entered only later by the responsible physician or even his/her colleagues simply for documentation purposes (if not entirely forgotten) questions the high hope of CPOE's beneficial impact on patient safety.

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      A similar trend was shown in a Children's Hospital.54 Three studies showed that the rate of order countersignatures improved.46,54,60 Using CPOE systems was found to be time-consuming for clinicians.

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    A list of the members of the Clinical Informatics Outcomes Research Group is available at www.jpeds.com.

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