Prescription errors and outcomes related to inconsistent information transmitted through computerized order entry: a prospective study.
Approach to Improving Safety
Setting of Care
Computerized provider order entry (CPOE) effectively prevents actual and potential medication errors, but a growing body of research has characterized new errors that may occur after implementation of CPOE. A new type of error is characterized in this study, in which investigators examined inconsistencies between CPOE order templates and free-text fields within the system. Approximately 1% of orders contained inconsistencies, usually relating to drug dosing. These inconsistencies had high potential for causing adverse drug events, as many occurred in orders for high-risk medications. This study reinforces the importance of integrating CPOE systems with provider workflow.