Analysis of variations in the display of drug names in computerized prescriber-order-entry systems

Abstract

A review of 10 CPOE systems revealed that medication names were displayed inconsistently, which can result in confusion or errors in reviewing, selecting, and ordering medications.

Computerized provider order entry–related medication errors among hospitalized patients: An integrative review

“…84 Displaying inconsistent names, especially the display of brand versus generic drug names, is a source of confusion when reviewing, selecting, and ordering medications. 83…”

“…An additional CPOE-related factor that might contribute to MEs is the way drug names are displayed. 83 A number of MEs were found to be related to screen displays and workflow issues. 84 Displaying inconsistent names, especially the display of brand versus generic drug names, is a source of confusion when reviewing, selecting, and ordering medications.…”

“…84 Displaying inconsistent names, especially the display of brand versus generic drug names, is a source of confusion when reviewing, selecting, and ordering medications. 83 Ineffective communications among nurses and physicians is another problem associated with CPOE use. The ability to enter orders through the system remotely can lessen the physical and visual interactions and may contribute to communication gaps.…”

Beyond mixed case lettering: reducing the risk of wrong drug errors requires a multimodal response

“…But physicians and other prescribers often make drug selections using computerised order entry systems where they see dropdown menus or lists of drug names (which may or may not use text enhancement), but never see any labels or packages. Similarly, changes to the user interface of computerised prescriber order entry systems,4 or the use of clinical decision supports such as indication alerts,5 6 while beneficial for some, will have no effect on the kinds of errors that nurses, pharmacists or pharmacy technicians might make in selecting products from a shelf or automated dispensing cabinet (ADC).…”

“…Schiff et al documented substantial variability in how drug names are represented on order entry screens, including inconsistency in display of brand and generic names, availability of clinical decision support for generic but not brand names, inability to search for combination products by individual ingredient names, truncation of drug names and inclusion of non-drug name information (such as indication) in drug name fields. 4 Initiating the ordering session with the indication (so-called indication-based prescribing) is an interface redesign technique that would all but eliminate wrong drug errors that were for different indications. In indication-based prescribing, the prescriber first inputs the indication and only then searches for a drug product, with search results only being drawn from drugs used for the specified indication.…”