Improving Medication Safety by Reducing Miscellaneous Orders Placed via CPOE

Named by The Joint Commission as a National Patient Safety Goal, medication safety is the focus of a multidisciplinary committee at a 173-bed community hospital in Northern California and the theme of this clinical nurse leader (CNL) project. “Improving Medication Safety by Reducing Miscellaneous Orders Placed via CPOE” aims to reduce the incidence of medication orders which bypass safety mechanisms when entered incorrectly in the computerized prescriber order entry (CPOE) system. After identification of this high-risk workaround, it was discovered that the nursing specific, free-text, orders were being used for medications and inadvertently bypassing clinical decision support systems, pharmacist verification, and the medication administration record. Upon approval by the multidisciplinary medication safety committee, an education module was assigned to all inpatient registered nurses at the hospital through an established forum. After allowing 30 days for completion of the module by nursing staff, this project anticipates a reduction in the amount of nurse-entered miscellaneous nursing orders containing medication information by 25% over 3 months. By working with key stakeholders to encourage the safe use of health information technology, this project aims to improve safe patient care and reduce the risk of medication errors