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PSNet: Patient Safety Network
Journal Article

Communication failure: analysis of prescribers' use of an internal free-text field on electronic prescriptions.

Ai A, Wong A, Amato MG, et al. J Am Med Inform Assoc. 2018;25(6):709-714.

Electronic prescribing is a pillar of patient safety, but computerized provider order entry may also introduce errors. This study examined the extent to which prescribers erroneously entered free text into electronic medication orders to communicate to pharmacists about medication. More than 10% of medication orders exhibited a communication failure between prescriber and pharmacist. Investigators also found that 38% of these communication failures conferred a risk for significant or severe harm to patients. This study demonstrates the need to facilitate communication between prescribers and pharmacists within the electronic ordering process to prevent adverse medication events. A past WebM&M commentary discussed strategies to reduce errors associated with electronic prescribing.