Analysis of variations in the display of drug names in computerized prescriber-order-entry systems.
OBJECTIVE
The variations in how drug names are displayed in computerized prescriber-order-entry (CPOE) systems were analyzed to determine their contribution to potential medication errors.


METHODS
A diverse set of 10 inpatient and outpatient CPOE system vendors and self-developed CPOE systems in 6 U.S. healthcare institutions was evaluated. A team of pharmacists, physicians, patient-safety experts, and informatics experts created a CPOE assessment tool to standardize the assessment of CPOE features across the systems studied. Hypothetical scenarios were conducted with test patients to study the medication ordering workflow and ways in which medications were displayed in each system. Brand versus generic drug name ordering was studied at 1 large outpatient system to understand why prescribers ordered both brand and generic forms of the same drug.


RESULTS
Widespread variations in the display of drug names were observed both within and across the 6 study sites and 10 systems, including the inconsistent display of brand and generic names. Some displayed drugs differently even on the same screen. Combination products were often displayed inconsistently, and some systems required prescribers to know the first drug listed in the combination in order for the correct product to appear in a search. It also appeared that prescribers may have prescribed both brand and generic forms of the same medication, creating the potential for drug duplication errors.


CONCLUSIONS
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.
Epidemiology Department, University of North Carolina at Chapel Hill, Chapel Hill, NC.
Arbor J L
AJ
Quist
Brigham and Women's Hospital, Wellesley, MA.
Thu-Trang T
TT
Hickman
Department of Pharmacy Practice, MCPHS University, Boston, MA.
Mary G
MG
Amato
Partners HealthCare, Wellesley, MA.
Lynn A
LA
Volk
Brigham and Women's Hospital, Boston, MA.
Alejandra
A
Salazar
Tufts University School of Medicine, Boston, MA.
Alexandra
A
Robertson
Brigham and Women's Hospital, Boston, MA.
Adam
A
Wright
Brigham and Women's Hospital, Boston, MA.
David W
DW
Bates
Brigham and Women's Hospital, Boston, MA.|Clinical Drug Information Division, Wolters Kluwer Health, Indianapolis, IN.
Shobha
S
Phansalkar
Northwestern University, Chicago, IL.
Bruce L
BL
Lambert
Brigham and Women's Hospital, Boston, MA. gschiff@partners.org.
Gordon D
GD
Schiff
D011307:Drug Prescriptions / Q000592:standards; D006801:Humans; D050316:Medical Order Entry Systems / Q000592:standards*; D008508:Medication Errors / Q000517:prevention & control*; D008510:Medication Systems, Hospital / Q000592:standards*; D012015:Reference Standards
CPOE (computerized prescriber order entry); drug name confusion; generic vs. brand names; medication errors