There’s many a slip…
Article Outline
An error is the result of an incorrect plan carried out perfectly, or a perfect plan carried out incorrectly (or not at all).1 We humans are so prone to the latter type of failure that there is a bountiful supply of adages noting that risk: “There’s many a slip ‘twixt the cup and the lip,” “The best-laid schemes o’ mice an’ men gang aft agley,”2 and so on. As Kaplan et al3 point out in this issue of The Journal, verbal orders represent a rich potential medium for errors of execution in healthcare, and they have added a new dimension to our understanding of verbal orders by describing their experience with verbal orders before, during, and after implementation of Computerized Provider Order Entry (CPOE).3 Although not claiming causality, the authors note downward trends in both the percentage of all orders that were verbally transmitted (in person or by telephone) and the percentage of all verbal orders that remained unsigned after 7 days, over a study period that began 4 months before the beginning of CPOE implementation and ended 21 months after the start of CPOE.
See related article, p 461
The decline in the percentage of unsigned verbal orders is an intended consequence of CPOE introduction, as a good CPOE system provides the physician with a tool that makes it far easier to sign verbal orders on a computer than was the case when each paper chart had to be found and then paged through manually. One unintended consequence of CPOE, however, might be an increase in the percentage of all orders that are expressed verbally, as physicians seek to avoid the use of a new system for order entry. Kaplan et al show that this is not a necessary consequence of CPOE implementation, and that should be good news for the many institutions embarking on CPOE implementations. The authors postulate that physicians who were off-site were able to substitute remote but direct online order entry for the pre-CPOE process of telephone-based orders, thereby contributing to the decrease in the rate of verbal orders. Undoubtedly, the contemporaneous process improvement efforts aimed at reducing the rate of verbal orders also had the desired effect. In fact, the introduction of CPOE became very much a part of that process improvement initiative, forcing increased accountability for orders (written or verbal) by the nature of the user interface (users are always clearly identified in the process of logging into any CPOE system).
One cannot help but wonder if the numerous data that are available from a CPOE system database are sufficient to tell a complete story of process changes. For example, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirement that verbal orders be recorded and then read back may be more easily performed with an easily portable sheet of order entry paper than with a computer that is at times less easily co-located with a face-to-face conversation or a telephone. Further, Vossmeyer has described the record and read-back process with the use of their CPOE system on physician work rounds in the context of attending and physician trainee discussions at the same institution (unpublished data). Does the same process hold for verbal orders outside of work rounds?
As another example of CPOE system data that could be misleading, a physician may enter an order into the CPOE system and also communicate the order to a nurse verbally. If there are forcing functions (not mere policies) that prevent the nurse from obtaining and administering the medication without first reviewing the order in the CPOE system or in a system to which the CPOE system is interfaced, then the risks inherent in a verbal order have been avoided. Without a forcing function (eg, controlled access medication cabinets interfaced to the pharmacy and CPOE systems), the risks would remain similar to those of a straightforward verbal order without “read-back,” regardless of whether the verbal order is ultimately signed or not.
It is possible that questions such as these could be answered by research, using direct observation of care providers. Flynn et al4 compared incident report review, chart review, and direct observation as methods for detecting medication errors and found direct observation to be the most generally accurate method, but also noted that it was much more expensive (7 times as expensive per examined dose when compared with the chart review method). Furthermore, as Han et al5 have reported, it is possible that patient outcomes could be negatively affected by CPOE implementation. That, one hopes, should make the added expense of more robust methods of study acceptable to organizations wishing to follow the example of Kaplan et al in advancing our understanding of changes in complex healthcare systems. According to The Systems Engineering Initiative for Patient Safety (SEIPS) model, such systems include five key elements: “… a care provider (person) performing various tasks using tools and technology in a given environment within an established organization …”6 As we begin to better understand the interplay among these elements triggered by introduction of new tools and technology, we can hope to further improve processes and outcomes while reducing the toll of unintended consequences.
References
- . Human Error. New York: Cambridge University Press; 1990;
- Burns R. To a Mouse. From the Kilmarnock Volume, 1786. Available at http://www.electricscotland.com/burns/mouse.html. Accessed June 19, 2006.
- . Inpatient verbal orders and the impact of computerized provider order entry. J Pediatr. 2006;149:461–467
- . Comparison of methods for detecting medication errors in 36 hospitals and skilled nursing facilities. Am J Health Syst Pharm. 2002;59:436–446
- . Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics. 2005;116;:1506–1512
- SEIPS Model. http://www2.fpm.wisc.edu/seips/. Accessed June 19, 2006.
PII: S0022-3476(06)00705-0
doi:10.1016/j.jpeds.2006.07.036
© 2006 Mosby, Inc. All rights reserved.
Refers to article:
- Inpatient verbal orders and the impact of computerized provider order entry
