Unacknowledged CPOE Improvement Project

The advent of computerized physician order entries (CPOE) paralleled the adoption of electronic medical records (EMR) (Zhivan & Diana, 2012). CPOE form the backbone of care provision for patients in hospital settings and have been recognized as a major factor in preserving patient safety (Wang et al, 2007). These electronic orders, however, do not guarantee prevention of medication administration errors (Wang et al, 2007). It is recognized that a major factor for CPOE as a safety feature is prompt acknowledgment of these orders by specialistsinvolved in direct patient care, e.g., nurses, especially procedure-linked orders (Koppel et al, 2005). Timely management of these phase of care orders is imperative to the efficiency of CPOEand the prevention of potentially dangerous workarounds and obsolete orders (Pirnejad et al, 2009). Additional patient safety benefits may have been identified directly linked to review of CPOE. For example, evidence suggests that when multiple specialties, e.g., pharmacists, nurses & physicians, review online orders prior to implementation mistakes are more easily identified (McLeod et al, 2019). In this academic medical center (MC), orders intended for the recovery period immediately after a procedure are entered before, or during the procedure, by the anesthesiologist. At times, due to patient location, these orders remain unacknowledged and are retained by the EMR for potentially up to six months, when outstanding orders are electronically reviewed. These recovery orders may be inadvertently acknowledged and implemented by the bedside nurse in a later phase of care. This can be a direct contributor to dissonance between orders and care received (Samaras et al, 2012). Occurrence of these orders has been observed 3 anecdotally by this author on one of many acute medicine floors that accepts patients from procedural areas in this MC. Utilizing a database of patient-related safety events maintained by this MC, three reported events were identified related to unacknowledged CPOE. One of these events was specifically related to orders from a prior procedure being acknowledged by a bedside nurse, with the ordered interventions being performed. Results included withholding nutrition and administering continuous maintenance fluid on a fluid-overloaded patient