Free-Text Computerized Provider Order Entry Orders Used as Workaround for Communicating Medication Information.
Free-Text Computerized Provider Order Entry Orders Used as Workaround for Communicating Medication Information.
复制标题
自由文本计算机化提供者订单输入订单用作传达药物信息的解决方法。
DOI：
10.1097/pts.0000000000000948
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发表时间：
2022
影响因子：
2.2
通讯作者：
Hettinger,AaronZ
中科院分区：
文献类型：
--
作者：
Kandaswamy,Swaminathan;Grimes,Joanna;Hoffman,Daniel;Marquard,Jenna;Ratwani,RajM;Hettinger,AaronZ
目标 药物信息经常通过电子健康记录中的自由文本计算机化提供者订单输入 (CPOE) 订单进行传达。当此类信息与结构化 CPOE 药物订单分开传输时，存在很大的用药错误风险。尽管先前的研究已经描述了使用自由文本 CPOE 指令来传达药物信息的频率，但在理解自由文本 CPOE 指令中包含的药物信息的性质方面存在差距。本研究的目的是 (1) 确定自由文本 CPOE 医嘱中传达的最常见药物名称及其风险水平，(2) 确定医生期望护士在下自由文本 CPOE 医嘱时完成哪些操作，以及 (3) 描述不同医院之间这些模式的差异。方法本研究对来自美国大西洋中部地区 6 家医院的 26,524 个自由文本 CPOE 医嘱样本进行了回顾性分析。结果自由文本样本中包含的 CPOE 命令提到了 193 种药物名称。自由文本 CPOE 订单经常用于传达有关纳洛酮、肝素、氟马西尼和葡萄糖的信息。 22% 的自由文本 CPOE 命令与停止用药有关，而 7% 的自由文本 CPOE 命令与给予药物有关。各医院在提及药物信息的自由文本 CPOE 医嘱的百分比以及提及高风险药物的比例方面存在很大差异。 结论 自由文本 CPOE 医嘱中药物信息的普遍存在可能表明在紧迫性、不确定性、计划以及沟通和临床需求的其他方面存在特定的沟通挑战。了解并解决围绕常见药物名称和操作（尤其是高风险药物名称和操作）的沟通挑战，有助于降低用药错误的风险。
ObjectivesMedication information is frequently communicated via free-text computerized provider order entry (CPOE) orders in electronic health records. When such information is transmitted separately from a structured CPOE medication order, there is a significant risk of medication error. Although prior studies have described the frequency of using free-text CPOE orders for communicating medication information, there is a gap in understanding the nature of the medication information contained in the free-text CPOE orders. The aims of this study are to (1) identify the most common medication names communicated in free-text CPOE orders and their risk levels and (2) identify what actions physicians expect that nurses will complete when they place free-text CPOE orders, and (3) describe differences in these patterns across hospitals.MethodsThis study was a retrospective analysis of a sample of 26,524 free-text CPOE orders from 6 hospitals in the mid-Atlantic US region.ResultsFree-text CPOE orders contained in the sample mentioned 193 medication names. Free-text CPOE orders were used frequently to communicate information about naloxone, heparin, flumazenil, and dextrose. Twenty-two percent of the free-text CPOE orders related to discontinuing medication (s), whereas 7% of the free-text CPOE orders relate to giving medication (s). There was high variation across hospitals both in the percentage of free-text CPOE orders mentioning medication information and in the proportion of those that referred to high-risk medications.ConclusionsThe prevalence of medication information in free-text CPOE orders may suggest specific communication challenges in respect to urgency, uncertainty, planning, and other aspects of communication and clinical needs. Understanding and addressing communication challenges around commonly mentioned medication names and actions, especially those that are high risk, can help reduce the risk of medication errors.