Abstract
Objectives:
Medication information is frequently communicated via free-text CPOE (Computerized Provider Order Entry) orders in electronic health records (EHRs). When such information is transmitted separately from a structured CPOE medication order, there is significant risk of medication error. While 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.
Methods:
This study was a retrospective qualitative analysis of a sample of 26,524 free-text CPOE orders from six hospitals in the mid-Atlantic United States region
Results:
Free-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. 22% of the free-text CPOE orders related to discontinuing medication(s), while 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 the proportion of those that referred to high-risk medications.
Conclusion:
The 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 risk of medication errors.
Introduction
Communication between health care providers is a critical component of safe and effective health care delivery. Communication failures contribute to 70% of sentinel events1 and 38% of malpractice incident claims involve miscommunication between providers.2 Poor communication among care providers cost US (United States) hospitals approximately $12 billion annually.3 Electronic Health Records (EHRs) are now ubiquitous, with 99% of large hospitals using a certified EHR.4 With EHRs increasingly being used in place of face-to-face communication5, it is essential that these technologies support effective communication.
One key form of communication between providers is Computerized Provider Order Entry (CPOE) systems. CPOE, allows providers to enter data in both structured and unstructured (free text) formats6 and send asynchronously, as opposed to synchronous communication in person or over a phone.7 While CPOE orders typically use both structured and free-text fields with set content, some CPOE order-types use solely free-text with minimal or no set content.8 These free-text CPOE order-types are often used by providers ad-hoc when a structured order or field does not meet their needs. Free-text CPOE orders could be used to communicate a wide range of information, including issues such as changing patient bandages, notifying staff of a scheduled procedure, or replacing IV lines.9 Individual healthcare organizations may customize and group free-text CPOE orders into functional categories, including for diets, nursing care tasks, or other needs, in an attempt to organize these types of orders.6,10
But free-text CPOE orders can create gaps in communication. They are typically visible to physicians and nurses, not to pharmacy, laboratory, blood bank, pantry, or other ancillary departments. For example, a study by Ai et. al. found that in 11.7% prescriptions, prescribers entered information intended for pharmacists in a field not sent to pharmacists.11 Free-text CPOE orders are also not included in the Medication Administration Record (MAR). Although all medication related information should be included within the MAR, prior work has shown that critical medication information is being communicated frequently via free-text CPOE orders, and thus is not included in the MAR.8,9 Additionally, CPOE features such as decision support, allergy alerts, and medication interaction checks cannot be utilized on free-text CPOE orders.12 These communication issues create potential for a patient not to receive medication, experience a delay in receiving the medication or receive a medication that should have been discontinued. A study on potential errors due to CPOE found that inappropriate use of free text fields contributed to both “duplicate drug prescription due to entering in the prescription and free text field” and “discrepancy between medication prescribed and free-text explanation” and account for 15.4% of errors associated with CPOE.13
While prior studies have described the frequency of using free-text CPOE orders for communicating medication information8,9 there is a gap in understanding details about the medication information communicated in 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.
Methods
We performed qualitative analysis on content of free-text CPOE orders used for communicating medication information and used descriptive statistics to answer the three research questions. Free-text CPOE orders were written by physicians at six hospitals in an academic nonprofit health system in the Mid-Atlantic United States region. The hospitals represented a mixture of medium to large academic facilities set in urban and suburban settings serving in both community and tertiary capacities. The healthcare system uses a single commercial electronic health record (EHR) that includes integrated CPOE and functions at the highest maturity levels with integrated health information exchange, high levels of electronic order entry, data analytics, governance and security.14 All free-text CPOE orders for a one-year period 1/1/2017 to 12/31/2017 were initially extracted through query of EHR database. A subset of the orders was sampled based on random stratification by hospital, patient type (inpatient, outpatient, etc.), month, and day of the week. A codebook for identifying orders with medication information was iteratively developed by authors [SK1, DJH and AZH] and is described in prior work.9 An order was considered as medication related if it included a medication name, information about a medication attribute (dose, timing, rate), and/or was confirming or documenting medication administration or intake. The orders that were identified as medication related were tagged with action types such as discontinuation, administration, hold, etc. that physicians wanted to carry out. The terms used to classify the action types in free-text CPOE orders are shown in Table1. Action types were further coded into risk levels for commission or omission errors, based on their risk if the requested action was not followed by the nurse. Free-text CPOE orders with the actions give, continue, resume, modify, do not stop, and do not hold pose risks of omission errors, which occur when a necessary medication or therapy is not carried out (omitted). Free-text CPOE orders with the actions discontinue, stop, hold, do not give, do not resume, and do not modify pose risks of commission errors, which occur when an incorrect medication is given or administered (committed).
Table 1:
Key words to capture action types mentioned in free-text CPOE orders.
| Action Type | Risk for Commission/Omission | Key Words |
|---|---|---|
| Discontinue | Commission | Discontinue, D/C, discontinuation, discontinued. |
| Give | Omission | Give, given, apply, transfuse, infuse, irrigate, start, initiate, replete, re-dose, readminister, titrate, run, put. |
| Hold | Commission | Hold, standby |
| Modify | Commission | Modify, early, late, increase, decrease, reschedule, reduce, switch, retime, extra dose, up titrate, titrate down, half dose, half rate. |
| Resume | Omission | Restart, resume |
| Stop | Commission | Stop, turn off, titrate off, wean off. |
| Continue | Omission | Continue, continuously, cont., keep, maintain Do not give Do not give, do not administer, do not apply, do not infuse, do not transfuse, do not irrigate, do not start. |
| Do not modify | Omission | Do not modify, do not adjust. |
| Do not resume | Commission | Do not resume. |
| Do not hold | Omission | Do not hold. |
| Other action | N/A | Free-text CPOE orders not categorized by the above |
Medication names were manually extracted (SK) from the free-text CPOE orders. Free-text CPOE orders that had medication information without mention of specific medication name(s) were coded as “not mentioned”. Orders requesting discontinuation of all medications, discontinuation of medications from specific order-sets, or stopping specific classes of medications like pain medications were considered “not mentioned”.
Medications designated as “high risk” are those that can cause significant patient harm if administered incorrectly. While medications considered high-risk may vary between hospitals and clinical units, the clinical excellence commission of New South Wales reviewed the published literature and identified a group of medications that should universally be considered as high-risk.15 This list includes the following groups of medications: Anti-infectives, Psychotropics, Potassium, Insulin, Narcotics, Chemotherapeutic agents, Heparin and other Anticoagulants, and Epidural Neuromuscular blocking agents. Error rates with these medications are not necessarily higher than with other medications, but when problems do occur the consequences can be severe.16 We coded the frequency of information regarding these high-risk medications in free-text CPOE orders. This study was approved by the health systems IRB
Results
A total of 667,429 free-text CPOE orders were written in the year of our analysis. The sample selection yielded 26,524 free-text CPOE orders. Of the 26,524 free-text CPOE orders, 42% (11,166) included medication related information. 22% of the free-text CPOE orders related to discontinuing medication(s) while 7% of the free-text CPOE orders related to giving medication [Figure 1]. The common “other action” category included free-text CPOE orders that asked for information regarding medications or were used for confirmation or documentation of a medication. The four negative action types of “Do not give”, “Do not hold”, “Do not resume”, “Do not modify” accounted for only 54 orders (0.002%). About 24% free-text CPOE orders carried a risk of commission error, while 8% carried a risk of omission error.
Figure 1:
Distribution of action types in free-text CPOE orders
Of the 26,524 free-text CPOE orders, 16% (4,176) mentioned a specific medication name. There were 193 different medication names mentioned in the free-text CPOE orders. Figure 2 shows the distribution of top 25 medication names mentioned in the free-text CPOE orders. A complete list of medication names and frequencies is shown in Appendix 1. Naloxone, Heparin, Flumazenil, and Dextrose were the most common medication names mentioned in free-text CPOE orders. More than one medication name was mentioned in 5.5% (1,470) of the free-text CPOE orders mentioned. A specific medication name was not mentioned in 26% (6,990) of the free-text CPOE orders though they had medication related information. For example, these orders requested holding/ resuming IV fluids, cancellation of all order set medications.
Figure 2:
Distribution of medication name frequency in free-text CPOE orders.
There was significant variability (2–15%, proportion test P value<0.001) across hospitals regarding the presence of high-risk medication names mentioned in free-text CPOE orders [Figure 3]. While Hospital 6 had lower proportion of their free-text CPOE orders containing medication information (26%), its proportion of free-text CPOE orders containing high-risk medication information was the highest (15%) of all hospitals and the high-risk medications accounted for 56% of their free-text CPOE orders containing medication-related information. Hospital 4 had 62% of their free-text CPOE orders containing medication information, but only 2% of free-text CPOE orders contained high-risk medication information.
Figure 3:
Percentage of free-text CPOE orders containing medication information stratified by risk and hospital.
We analyzed example free text orders for high-risk medication orders. Orders were frequently used to modify and update an existing medication order such as “give regular insulin 5u IV x1, increase insulin gtt to 14u/h”, “please run blood over 2 hours”, “D/c heparin drip at [hh:mm] on [dd/mm] for line placement by IR”. We also found free-text CPOE orders specifying workflows, including medication regiments that seemed to be poorly supported in the EHRs. For example, “give norvasc first then recheck blood pressure after one hour, then give Hydralazine if SBP>175”; “ok to run D10 until TPN is administered”. Providers did not have a way to indicate these details in a structured CPOE order to accommodate medications based on conditions and procedures.
Discussion
We found that free text orders were common for high-risk medications such as titratable medications (e.g. heparin, insulin), and reversal agents (e.g., naloxone, flumazenil). Mentioning these specific medication names in free-text CPOE orders may indicate that there are safety concerns that are not addressed by the medication orders themselves, for example discrete fields to guide titration. The rate of high-risk medications in free text orders may be a useful surveillance mechanism for identifying usability and workflow issues that put patients at risk. The analysis also found that free-text CPOE orders were sometimes used for negation actions, indicating communication update contrary to an existing order or and earlier communication. Though these were infrequent, these may be an indication of poor communication support structure for medication information requiring caution from providers. Free-text workarounds may be due to cumbersome interactions or complex navigation required to achieve this within the structured orders, as reported in other studies showing adoption of workarounds due to usability issues. 17,18
There was substantial variability in the proportion of free text orders including the names of high-risk medications across hospitals, suggesting that different EHR and workflow configurations may lead to different frequency of this workaround. Efforts to reduce safety events associated with high-risk medications19,20 may benefit from focusing on those with high levels of free text orders and a deeper dive into the socio-technical challenges leading providers to follow these workarounds. For examples, Heparin was the second most common high-risk medication mentioned in free-text CPOE orders and is a known source of serious medication safety events.21,22 Free-text orders regarding such high-risk medications do not allow use of evidence-based strategies such as dose checking, drug-drug interactions, monitoring protocols, and discrete values for analytics.12,23
We found that discontinuation of medications was the most common action requested in the free-text CPOE orders. Discontinuation of medications is especially challenging because nurses might fail to see that the orders were discontinued or should be discontinued due to lack of functionality and usability within the EHRs.24 Though the orders drop off the medication list when discontinued, detecting these changes to the medication list in the EHR interface is difficult. In a study by Koppel et al, 51% participants (n=261) responded that discontinuation failures occur “for at least several hours” from not seeing patients’ complete medication records.25 Free-text CPOE orders might be used as a safety net by physicians to alert other providers about these changes.24 However, this is also not ideal as nurses can miss this information in free-text CPOE orders. A study that analyzed prescribers’ use of an internal free-text field on electronic prescriptions found that a third of the comments that were not visible to pharmacists contained information that had the potential for significant or severe harm if not communicated.11 Another challenge with discontinuation of medication is that procedure linked medications are not cancelled when procedures are cancelled.25 Hence, physicians might forget to cancel orders, leading to commission errors. One potential solution is to allow providers to tag procedure-linked medications while ordering medications so they can follow up on these orders based on the status of the procedure.
These findings suggest that the EHR may not fully support provider needs around discontinuing medications, forcing them to use free-text CPOE orders as a workaround. A study on health IT related medication errors found that free text as either a communication order or as a component within a medication order describing when to hold or discontinue a medication was the most common cause of patients receiving extra doses of medication.22 In certain cases, there is no structured way for physicians to ask nurses to temporarily hold medications.24 This shows that EHR needs to adopt to varying clinician requirements and support flexible workflows while accurately reflecting the care of patients and providing safety guidance to prevent errors.
There are several limitations with the study. The data reported is from 2017 and there may be changes in the usage patterns. However, it is unlikely that all of the usability and safety concerns represented in this study have been solved since the data was collected. The results are constrained by the analysis of free-text CPOE orders without clinical context of why the order was placed. This study looked at the medication information in free-text CPOE orders but did not corelate with actual errors. Future study should compare these patterns across organizations and vendor systems. Though the analysis found significant variation in high-risk medications, the classification of “high-risk” can vary based on local practice and clinical context. Any medication can fall into a high-risk category. The reference list “APINCH” used in this study, from Clinical Excellence Commission has been updated since completion of analysis of this study. Nonetheless, the list used in the study is a starting point at analyzing the use of free-text and local analysis can be carried out to identify use of free-text CPOE orders for specific high-risk medications. The study identified a large proportion for free-text CPOE orders with no specific medication information. Many of these seem to be part of an order set which can sometime utilize free-text CPOE orders to supplement the structured orders. There was no analysis to determine if the orders were part of the order set. More research is needed in this area to determine free-text use patterns associated with order sets, including the standard use of free-text CPOE orders associated with rescue/antidote medications like naloxone and flumazenil. Finally. results are based on a single hospital system using the same version of EHR and hence may not generalize to all EHR products or the same product implemented at a different healthcare organization.
Conclusion
The study provided insights into the use of free-text CPOE orders and revealed variation in the use of free-text CPOE orders is across hospitals, medications, and provider action requirements. Discontinuation was the most common action requirement and free-text CPOE orders were used frequently for Naloxone, Heparin, Flumazenil and Dextrose. Understanding communication challenges around these specific issues and addressing them can help reduce risk of medication errors.
Acknowledgements:
This manuscript was supported in part by grants numbers R01HS025136 and R21 HS024755 from the Agency for Healthcare Research and Quality.
Appendix
Appendix 1.
Medication names and frequency of appearance in free-text CPOE orders
| Medication Name | Count |
|---|---|
| Not Mentioned* | 6990 |
| Naloxone | 923 |
| Heparin | 901 |
| Flumazenil | 656 |
| Dextrose | 369 |
| Glucagon Hydrochloride | 319 |
| Saline | 270 |
| Enoxaparin | 234 |
| Insulin | 203 |
| Cefazolin | 144 |
| Fondaparinux | 139 |
| Chlorhexidine | 138 |
| Dabigatran | 135 |
| Blood | 118 |
| Rivaroxaban | 114 |
| Lidocaine | 91 |
| Epinephrine | 90 |
| Phenytoin | 89 |
| Valproic Acid | 89 |
| Carbamazepine | 88 |
| Insulin Glargine | 84 |
| Argatroban | 78 |
| Eptifibatide | 73 |
| Digoxin | 72 |
| Sucrose | 56 |
| Metoprolol | 44 |
| Warfarin | 40 |
| Norepinephrine | 39 |
| Dobutamine | 27 |
| Hydralazine | 27 |
| Diphenhydramine | 26 |
| Epidural | 26 |
| Dopamine | 25 |
| Nicardipine | 25 |
| Aspirin | 23 |
| Labetalol | 20 |
| Furosemide | 19 |
| Vancomycin | 19 |
| Clopidogrel | 18 |
| Propofol | 17 |
| Scopolamine | 16 |
| Anticoagulant | 15 |
| Metformin | 14 |
| Milrinone | 14 |
| Potassium | 14 |
| Apixaban | 12 |
| Erythromycin | 12 |
| Acetaminophen | 10 |
| Insulin Lispro | 10 |
| Amiodarone Hydrocholoride | 9 |
| Morphine | 9 |
| Nitroglycerin | 9 |
| Vaccine | 9 |
| Alteplase | 8 |
| Dihydroergotamine | 8 |
| Docusate Sodium | 8 |
| Hydromorphone | 8 |
| Magnesium Citrate | 8 |
| Polyethylene Glycol 3350 | 8 |
| Clindamycin | 7 |
| Oxycodone | 7 |
| Polyethylene Glycol | 7 |
| Amlodipine | 6 |
| Lisinopril | 6 |
| Metronidazole | 6 |
| Rituximab | 6 |
| Calcium | 5 |
| Carvedilol | 5 |
| Petroleum Dressing | 5 |
| Piperacillin | 5 |
| Tacrolimus | 5 |
| Dexmedetomidine | 4 |
| Diltiazem | 9 |
| Fentanyl | 4 |
| Gentamicin | 4 |
| Ibuprofen | 4 |
| Ondansetron | 4 |
| Aquacel Silver | 3 |
| Atropine | 3 |
| Bacitracin | 3 |
| Bumetanide | 3 |
| Clonidine | 3 |
| Collagenase | 3 |
| Dexamethasone | 3 |
| Olanzapine | 3 |
| Tramadol | 3 |
| Albumin Human | 2 |
| Ampicillin | 2 |
| Ceftriaxone | 2 |
| Cyclosporine | 2 |
| Enema | 2 |
| Erythropoietin | 2 |
| Glucan | 2 |
| Ketorolac | 2 |
| Lorazepam | 2 |
| Midodrine | 2 |
| Mirtazapine | 2 |
| Nutritional Supplement | 2 |
| Octreotide | 2 |
| Pantoprazole | 2 |
| Povidone-Iodine | 2 |
| Quetiapine | 2 |
| Ringers Lactate Solution | 2 |
| Silver Sulfadiazine | 2 |
| Statin | 2 |
| Thiamine | 2 |
| Trazodone | 2 |
| Treprostinil | 2 |
| Butalbital | 1 |
| Acetazolamide | 1 |
| Acetylsalicylic Acid | 1 |
| Acyclovir | 1 |
| Albuterol | 1 |
| Aripiprazole | 1 |
| Atenolol | 1 |
| Azithromycin | 1 |
| Barium | 1 |
| Barrier Cream | 1 |
| Benzalkonium Chloride | 1 |
| Bicarbonate | 1 |
| Bivalirudin | 1 |
| Bleomycin | 1 |
| Buspirone | 1 |
| Cadexomer Iodine | 1 |
| Cefepime | 1 |
| Cefoxitin | 1 |
| Ceftazidime | 1 |
| Ciprofloxacin | 1 |
| Clonazepam | 1 |
| Cosyntropin | 1 |
| Cyanoacrylate | 1 |
| Demeboro | 1 |
| Dextrin | 1 |
| Dialysate | 1 |
| Epoprostenol | 1 |
| Filgrastim | 1 |
| Gabapentin | 1 |
| Glycopyrrolate | 1 |
| Guaifenesin | 1 |
| Haloperidol | 1 |
| Hetastarch | 1 |
| Hydrocortisone | 1 |
| Hydrogen Peroxide | 1 |
| Hydroxyzine | 1 |
| Immune Globulin | 1 |
| Indapamide | 1 |
| Iodoform | 1 |
| Ketamine | 1 |
| Ketorolac Tromethamine | 1 |
| Lactate Ringers | 1 |
| Lactulose | 1 |
| Ledipasvir /Sofosbuvir | 1 |
| Levalbuterol | 1 |
| Levetiracetam | 1 |
| Levothyroxine | 1 |
| Lithium | 1 |
| Losartan | 1 |
| Magnesium | 1 |
| Medihoney | 1 |
| Meropenem | 1 |
| Mesna | 1 |
| Methimazole | 1 |
| Methylnaltrexone | 1 |
| Methylprednisolone | 1 |
| Midazolam | 1 |
| Multiple Ingredients | 1 |
| Mycophenolic Acid | 1 |
| Nature Thyroid | 1 |
| Nicotine | 1 |
| Nifedipine | 1 |
| Oxcarbazepine | 1 |
| Oxygen | 1 |
| Pancrelipase | 1 |
| Patient Controlled Analgesia | 1 |
| Pedialyte | 1 |
| Penicillin | 1 |
| Petroleum Jelly | 1 |
| Phenazopyridine | 1 |
| Phenobarbital | 1 |
| Phenylephrine | 1 |
| Pomalidomide | 1 |
| Prednisone | 1 |
| Prochlorperazine | 1 |
| Regular Human Insulin | 1 |
| Rosuvastatin | 1 |
| Silver | 1 |
| Silver Sulfadiazine | 1 |
| Sodium Hypochlorite | 1 |
| Sulfamethoxazole | 1 |
| Ticagrelor | 1 |
| Triamcinolone | 1 |
| Valsartan | 1 |
| Vasopressin | 1 |
| Zinc Sulfate | 1 |
Note: Not mentioned category includes free-text CPOE orders that mentioned IV fluids, order set medications without any specifics, or resumption/discontinuation of all patient meds
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