The DOI matches its Crossref record; 28 of the 29 references it cites were found in a registry or an index; none of the 25 sources its claims cite is checked for support yet.
Prescription Errors and Outcomes Related to Inconsistent Information Transmitted Through Computerized Order Entry: A Prospective Study
Open accessAbstract
BACKGROUND: Although several types of computerized provider order entry (CPOE)-related errors may occur, errors related to inconsistent information within the same prescription (ie, mismatch between the structured template and the associated free-text field) have not been described, to our knowledge. We determined the nature and frequency of such errors and identified their potential predictive variables. METHODS: In this prospective study, we enrolled pharmacists to report prescriptions containing inconsistent communication over a 4-month period at a tertiary care facility. We also electronically retrieved all prescriptions written during the study period containing any comments in the free-text field and then randomly selected 500 for manual review to determine inconsistencies between free-text and structured fields. Of these, prescriptions without inconsistencies were categorized as controls. Data on potentially predictive variables from reported and unreported errors and controls were collected. For all inconsistencies, we determined their nature (eg, drug dosage or administration schedule) and potential harm and used multivariate logistic regression models to identify factors associated with errors and harm. RESULTS: Of 55 992 new prescriptions, 532 (0.95%) were reported to contain inconsistent communication, a rate comparable to that obtained from the unreported group. Drug dosage was the most common inconsistent element among both groups. Certain medications were more likely associated with errors, as was the inpatient setting (odds ratio, 3.30; 95% confidence interval, 2.18-5.00) and surgical subspecialty (odds ratio, 2.45; 95% confidence interval, 1.57-3.82). About 20% of errors could have resulted in moderate to severe harm, for which significant independent predictors were found. CONCLUSIONS: Despite standardization of data entry, inconsistent communication in CPOE poses a significant risk to safety. Improving the usability of the CPOE interface and integrating it with workflow may reduce this risk.
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A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Medications needing a complex order (eg, a tapering dose of prednisone) were highly correlated with error.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > RESULTS
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In the paper
“Second, comments were transferred to the new prescription when modifying an existing prescription.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > COMMENT
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In the paper
“Certain medication classes were also more likely to have errors, with the highest odds of error occurring for steroids (OR, 7.62; 95% CI, 3.11–18.63) compared with analgesics.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > RESULTS
Strength:plain· not yet calibratedCausal:correlational· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Most errors (68.3%) occurred in prescriptions for inpatients,”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > RESULTS
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“112 errors could have resulted in moderate to severe harm (considerable, very serious, serious permanent damage, or death) (20.1%).”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > RESULTS
Load-bearingStrength:hedged· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Orders with inconsistent communication were most commonly entered by trainees (59.0%), followed by attending physicians (24.9%), physician assistants (10.2%), and nurse practitioners (5.4%).”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > RESULTS
Strength:plain· not yet calibratedCausal:correlational· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“In the 26 unreported errors, dosage inconsistency was also the most common (n=10; data not shown).”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > RESULTS
Strength:plain· not yet calibratedn = 10Tests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Of 55 992 new prescriptions processed and reviewed by the pharmacists in the study period, 532 were reported by pharmacists to contain inconsistent communication (0.95%).”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > RESULTS
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“and 19.0% (n=103) had 2 or more inconsistencies.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > RESULTS
Strength:plain· not yet calibratedn = 103Tests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The most common inconsistent element across reported prescriptions was drug dosage (44.9%),”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > RESULTS
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Medications ordered by providers in specialties other than primary care and surgery had lower risk (OR, 0.30; 95% CI, 0.14–0.63) than those ordered by providers in primary care.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > RESULTS
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Anticoagulants and cardiovascular drugs were the most frequent categories involving moderate to severe harm.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > RESULTS
Strength:plain· not yet calibratedCausal:correlational· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Medications ordered by providers in the outpatient setting had higher risk (OR, 2.23; 95% CI, 1.15–4.35) for causing moderate to severe harm than those ordered for inpatients.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > RESULTS
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“From the remaining 491 prescriptions containing comments, 26 were found to contain inconsistent communication (5.3%); none reported by pharmacists.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > RESULTS
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The following medication classes were most commonly affected by errors: cardiovascular and antihypertensives (15.8%), analgesics (14.7%), antibiotics (10.8%), psychiatric medications (10.4%), and laxatives (7.5%).”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > RESULTS
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“providers would often use the free-text window to write complex prescriptions that were frequently associated with error (eg, prednisone taper).”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > COMMENT
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Pharmacists called providers in 149 cases (28.0%).”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > RESULTS
Strength:plain· not yet calibratedn = 149Tests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Of all medication classes, anticoagulants were associated with the highest risk of causing potentially moderate to severe harm (OR, 61.89; 95% CI, 10.73–356.93).”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > RESULTS
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“As expected, medications considered high alert (OR, 3.43; 95% CI, 1.62–7.27) had a high potential for causing moderate to severe harm.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > RESULTS
Strength:plain· not yet calibratedCausal:correlational· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesNone of the sources cited for this claim have been checked yet.
In the paper
“Errors facilitated by CPOE have received increasing attention in the literature, yet the true frequency of the problem is unknown.9,11,12”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > BACKGROUND
What the sources say
- Not checked yetcites [9] Koppel R Metlay JP Cohen A Role of computerized physician order entry systems in facilitating medication errors JAMA 2005 March 9 293 10 1197 203 15755942
- Not checked yetcites [11] Kaushal R Shojania KG Bates DW Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review Arch Intern Med 2003 June 23 163 12 1409 16 12824090
- Not checked yetcites [12] Nebeker JR Hoffman JM Weir CR Bennett CL Hurdle JF High rates of adverse drug events in a highly computerized hospital Arch Intern Med 2005 May 23 165 10 1111 6 15911723
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesNone of the sources cited for this claim have been checked yet.
In the paper
“However, computerization may introduce new error pathways.5–10”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > BACKGROUND
What the sources say
- Not checked yetcites [5] Ash JS Berg M Coiera E Some unintended consequences of information technology in health care: the nature of patient care information system-related errors J Am Med Inform Assoc 2004 March 11 2 104 12 14633936 PMC353015
- Not checked yetcites [6] Berger RG Kichak JP Computerized physician order entry: helpful or harmful? J Am Med Inform Assoc 2004 March 11 2 100 3 14633934 PMC353014
- Not checked yetcites [7] Harrison MI Koppel R Bar-Lev S Unintended consequences of information technologies in health care--an interactive sociotechnical analysis J Am Med Inform Assoc 2007 September 14 5 542 9 17600093 PMC1975796
- Not checked yetcites [8] Horsky J Kuperman GJ Patel VL Comprehensive analysis of a medication dosing error related to CPOE Journal Of The American Medical Informatics Association: JAMIA 12 4 377 82 15802485 PMC1174881
- Not checked yetcites [9] Koppel R Metlay JP Cohen A Role of computerized physician order entry systems in facilitating medication errors JAMA 2005 March 9 293 10 1197 203 15755942
- Not checked yetcites [10] Weiner JP Kfuri T Chan K Fowles JB “e-Iatrogenesis”: the most critical unintended consequence of CPOE and other HIT J Am Med Inform Assoc 2007 May 14 3 387 8 17329719 PMC2244888
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesA conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Third, insufficient knowledge of the ordering mechanism appears to be a common problem,”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > COMMENT
Load-bearingStrength:hedged· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIn the paper
“Our results suggest that despite attempted standardization of data entry, inconsistent communication poses significant risks to safety achieved by computerized medication order entry.2”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > COMMENT
What the sources say
- Not checked yetcites [2] Bates DW Leape LL Cullen DJ Effect of computerized physician order entry and a team intervention on prevention of serious medication errors JAMA 1998 October 21 280 15 1311 6 9794308
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesNone of the sources cited for this claim have been checked yet.
In the paper
“Our study adds to the growing body of knowledge that computerized information systems may introduce new types of errors, including those involving communication processes.5,25”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > COMMENT
What the sources say
- Not checked yetcites [5] Ash JS Berg M Coiera E Some unintended consequences of information technology in health care: the nature of patient care information system-related errors J Am Med Inform Assoc 2004 March 11 2 104 12 14633936 PMC353015
- Not checked yetcites [25] Campbell EM Sittig DF Ash JS Guappone KP Dykstra RH Types of Unintended Consequences Related to Computerized Provider Order Entry J Am Med Inform Assoc 2006 September 1 13 5 547 56 16799128 PMC1561794
Tests✓ Asserted: passes? Checkable: unclear✓ Load-bearing: passes✓ Based: passesWhat the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“A review of 80 random records validated quality of data entry. Of 5600 pieces of information collected in these 80 records, 5591 (99.8%) were found to be correct.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > BACKGROUND > Data Analysis
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesA conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“First, providers often selected an automated dosage default rather than typing the desired dosage.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > COMMENT
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesA conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The flexibility, however, can lead to discrepancies between the elements selected through the structured template and the provider’s free-text comments (Figure 1).”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > BACKGROUND
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesA conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Based on a 5.3% error rate in prescriptions with comments, we estimated the 157 055 prescriptions with comments might contain 8324 prescriptions with inconsistent communication (5.3%).”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > RESULTS
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesA conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“it appeared that providers did not realize many could be changed.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > COMMENT
Load-bearingStrength:hedged· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIn the paper
“Narrative instructions in the free-text field have advantages in highly structured order entry forms14 because they allow flexibility for providers to enter clarifications regarding timing, dosage, or route of administration.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > BACKGROUND
What the sources say
- Not checked yetcites [14] McDonald CJ Overhage JM Mamlin BW Dexter PD Tierney WM Physicians, Information Technology, and Health Care Systems: A Journey, Not a Destination J Am Med Inform Assoc 2004 March 1 11 2 121 4 15027445 PMC353017
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesNone of the sources cited for this claim have been checked yet.
In the paper
“Finally, many of the errors and issues suggest that standardization through CPOE was not adequately integrated with the workflow, needs, and preferences of the providers.23,24”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > COMMENT
What the sources say
- Not checked yetcites [23] Campbell EM Guappone KP Sittig DF Dykstra RH Ash JS Computerized Provider Order Entry Adoption: Implications for Clinical Workflow Journal of General Internal Medicine In press 2008 PMC2607519 19020942
- Not checked yetcites [24] Aarts J Ash J Berg M Extending the understanding of computerized physician order entry: implications for professional collaboration, workflow and quality of care Int J Med Inform 2007 June 76 Suppl 1 S4 13 16798068
Tests✓ Asserted: passes? Checkable: unclear✓ Load-bearing: passes✓ Based: passesWhat the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Because underreporting is a well recognized phenomenon in similar studies, our findings may underestimate the problems caused by inconsistencies in the orders;”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > COMMENT
Strength:hedged· not yet calibratedCausal:conditional· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passes- Rests on an assumption: Underreporting is a well-recognized phenomenon in similar studies.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“we estimate the overall rate of errors of inconsistent information to be 1% (8324 of 830 823).”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > RESULTS
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes
- It may state two separate claims as one. 17
- Probably not a substantial claim. 15
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Pharmacists used the free-text comment in 88.9% of cases to fill the final prescription, the structured template in 9.2% of cases, and in combination in the remainder (1.9%).”
- Also stated in: § COMMENT · hedged
“in over 90% of cases the pharmacists used the free-text information either by itself or combined it with information from the structured template”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > RESULTS
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
- Also stated in: § COMMENT · hedged
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Only 2 reported errors were discovered after reaching the patient and did not result in harm.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > RESULTS
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesIt may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The following variables differed significantly between the 2 groups: ordering provider type (P=.04) and specialty (P<.001), inpatient vs outpatient setting (P<.001), and medication class (P<.001).”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > RESULTS
Tests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesIt may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Of note, 23.1% of unreported errors could have resulted in moderate to severe harm, statistically no different from reported errors (P=.62).”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > RESULTS
Load-bearingStrength:hedged· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Inpatient setting (OR, 3.30; 95% CI, 2.18–5.00) and non–primary care specialties such as surgery (OR, 2.45; 95% CI, 1.57–3.82) were more likely to have errors.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > RESULTS
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
None of the sources cited for this claim have been checked yet.
In the paper
“many types of CPOE-related errors have been described in recent years.5–10”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > BACKGROUND
What the sources say
- Not checked yetcites [5] Ash JS Berg M Coiera E Some unintended consequences of information technology in health care: the nature of patient care information system-related errors J Am Med Inform Assoc 2004 March 11 2 104 12 14633936 PMC353015
- Not checked yetcites [6] Berger RG Kichak JP Computerized physician order entry: helpful or harmful? J Am Med Inform Assoc 2004 March 11 2 100 3 14633934 PMC353014
- Not checked yetcites [7] Harrison MI Koppel R Bar-Lev S Unintended consequences of information technologies in health care--an interactive sociotechnical analysis J Am Med Inform Assoc 2007 September 14 5 542 9 17600093 PMC1975796
- Not checked yetcites [8] Horsky J Kuperman GJ Patel VL Comprehensive analysis of a medication dosing error related to CPOE Journal Of The American Medical Informatics Association: JAMIA 12 4 377 82 15802485 PMC1174881
- Not checked yetcites [9] Koppel R Metlay JP Cohen A Role of computerized physician order entry systems in facilitating medication errors JAMA 2005 March 9 293 10 1197 203 15755942
- Not checked yetcites [10] Weiner JP Kfuri T Chan K Fowles JB “e-Iatrogenesis”: the most critical unintended consequence of CPOE and other HIT J Am Med Inform Assoc 2007 May 14 3 387 8 17329719 PMC2244888
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“We obtained a comparable estimate of error rate (ie, 1%) using both reporting and electronic search, adding strength to our findings.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > COMMENT
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“approved by the local institutional review board and the MEDVAMC research and development committee.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > BACKGROUND > Methods
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Although most errors we studied did not reach the patient because of pharmacist intervention, they pose a significant potential risk to patients.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > COMMENT
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Additional study strengths include a large variety of medications, a large number of providers (>500), and an advanced CPOE system fairly representative of other systems.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > COMMENT
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesIt may state two separate claims as one.
- Rests on an assumption: The advanced CPOE system used in the study is fairly representative of other CPOE systems.
In the paper
“Chused et al21 recently reported communication failures resulting from free-text comments entered in response to alert overrides, suggesting that commercial CPOE systems may not also protect against the problem.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > COMMENT
What the sources say
- Not checked yetcites Chused et al21
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesProbably not a substantial claim. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Although defaults can be helpful, they may not be comprehensive and may be based on inventory rather than clinical guidelines.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > COMMENT
Load-bearingStrength:hedged· not yet calibratedTests✓ Asserted: passes✗ Checkable: fails✓ Load-bearing: passes✓ Based: passesProbably not a substantial claim. It may be too vague to check against evidence. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The potential for moderate to severe harm is likely more significant given the expected increase in the volume of prescriptions written through future CPOE systems.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > COMMENT
Strength:hedged· not yet calibratedCausal:conditional· not yet calibratedTests✓ Asserted: passes✗ Checkable: fails✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. It may be too vague to check against evidence. The paper’s conclusions may not depend on it.
In the paper
“Because poor communication is an often-cited preventable factor in adverse events,15”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > BACKGROUND
What the sources say
- Not checked yetcites [15] Joint Commission on Accreditation of Healthcare Organizations Sentinel event statistics, March 31, 2006 Joint Commission on Accreditation of Healthcare Organizations 2005 Available at: URL: http://www.jointcommission.org/NR/rdonlyres/FA465646-5F5F-4543-AC8F-E8AF6571E372/0/root_cause_se.jpg 17139928
Strength:plain· not yet calibratedCausal:correlational· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“we found errors that could be prevented by minor modifications in the CPOE template regarding administration time or duration and/or stop time for a medication.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > COMMENT
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“To ensure that the model had stable and precise estimates of ORs, variables with small numbers of patients with a given characteristic (eg, ordering providers listed as clinical support, clinical specialist, or unknown) were removed or combined (eg, geriatrics, other medicine, spinal cord injury, and psychiatry specialties were all combined as “other specialties” in the model to predict harm), and”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > BACKGROUND > Data Analysis
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Only slightly more than two-thirds of eligible pharmacists participated in the study, and hence there is almost certainly selection bias.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > COMMENT
Strength:boosted· not yet calibratedCausal:direct· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear? Based: unclearIt may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Even though most errors of inconsistent communication would have caused inconvenience or minor harm, the potential for more severe harm is significant, given the large volume of prescriptions written.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > COMMENT
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“A generalized estimating equation approach in which errors were nested within providers allowed us to account for the potential correlation among errors.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > BACKGROUND > Data Analysis
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesProbably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“while it is likely that similar communication breakdowns occur in other Veterans Affairs facilities using the same CPOE system, we ac-knowledge that the true prevalence across Veterans Affairs institutions is unknown.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > COMMENT
Strength:hedged· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✗ Based: failsProbably not a substantial claim. The paper’s conclusions may not depend on it. The paper may give no reason why it holds. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“the free-text comments are printed on the label of the dispensed medication, which may confuse or harm the patient.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > BACKGROUND
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesProbably not a substantial claim. It may state two separate claims as one.
- Rests on an assumption: Free-text comments are printed on the label of the dispensed medication.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“simple training on the use of complex orders for certain prescriptions could reduce errors.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > COMMENT
Tests✓ Asserted: passes✗ Checkable: fails✓ Load-bearing: passes✓ Based: passesProbably not a substantial claim. It may be too vague to check against evidence.
In the paper
“a study using both qualitative and quantitative methods to study house staff interaction with a CPOE system at a tertiary care facility identified 22 different types of medication errors, including fragmented CPOE displays and inflexible ordering formats.9”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > BACKGROUND
What the sources say
- Not checked yetcites [9] Koppel R Metlay JP Cohen A Role of computerized physician order entry systems in facilitating medication errors JAMA 2005 March 9 293 10 1197 203 15755942
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“It was conducted at a single site where all providers used the same CPOE system, and although it involved a large number of patients and providers, including trainees, generalizability may be limited.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > COMMENT
Strength:hedged· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesIt may state two separate claims as one.
In the paper
“Two investigators (a physician and pharmacist) assigned harm categories by consensus using the Human Error Consequence Scale20 after evaluating the results from the initial data collection.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > BACKGROUND > Data Collection
What the sources say
- Not checked yetcites [20] Gilpatrick E Health Services Mobility Study Final Report (October 1967-March 1972) New York, NY City Univ. of New York Research Foundation 1972 Jan 1 Report No.: ERIC Reports ED066613
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“the free text window offers a valuable option to communicate clarifications or nonstandard information.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > COMMENT
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✗ Checkable: fails✓ Load-bearing: passes✓ Based: passesProbably not a substantial claim. It may be too vague to check against evidence.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Of 45 pharmacists, 33 agreed to report errors.”
§ Prescription Errors and Outcomes Related to Inconsistent Information Transmitted through Computerized Order-Entry: A Prospective Study > BACKGROUND > Methods
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it.
The paper relies on this without support.
Order entry errors related to inconsistent information within the same prescription had not been described before this study.
“To our knowledge, order entry errors related to inconsistent information within the same prescription have not been described.”
The paper relies on this without support.
This is the first study reporting errors of communication due to free-text comments in CPOE systems.
“To our knowledge, this is also the first study reporting errors of communication due to free-text comments in CPOE systems.”
The paper relies on this without support.
All CPOE systems have some method of entering free text.
“All CPOE systems have some method of entering free text.”
The paper relies on this without support.
Underreporting is a well-recognized phenomenon in similar studies.
“Because underreporting is a well recognized phenomenon in similar studies”
The paper relies on this without support.
Free-text comments are printed on the label of the dispensed medication.
“the free-text comments are printed on the label of the dispensed medication”
The paper relies on this without support.
The advanced CPOE system used in the study is fairly representative of other CPOE systems.
“an advanced CPOE system fairly representative of other systems”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
In the citing paper
“In particular, rapid adoption of electronic health records (EHRs) has revealed potential safety concerns related to EHR design, implementation, and use.12 17–21”
From An analysis of electronic health record-related patient safety concerns (2014) · cites this paper as [17]
In the citing paper
“the increasing adoption of electronic health records (EHR) has revealed potential safety implications related to EHR design, implementation, and use.”
From Exploring the sociotechnical intersection of patient safety and electronic health record implementation (2014) · cites this paper as [11]
Citations
Cites
Institute of Medicine (2000) · National Academies Press eBooks · doi:10.17226/9728 · Cited by 14,390
Incidence of Adverse Drug Events and Potential Adverse Drug Events: Implications for Prevention
Bates, D. W. (1995) · JAMA · doi:10.1001/jama.1995.03530010043033 · Cited by 2,127
Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors
Koppel, R. (2005) · JAMA · doi:10.1001/jama.293.10.1197 · Cited by 2,126
Bates, D. W. (1998) · JAMA · doi:10.1001/jama.280.15.1311 · Cited by 2,107
Ash, J. S. (2003) · Journal of the American Medical Informatics Association · doi:10.1197/jamia.m1471 · Cited by 1,789 · cited 1×
“Our study adds to the growing body of knowledge that computerized information systems may introduce new types of errors, including those involving communication processes.(5,25) Future studies should address the usability of the CPOE interface to identify breakdown points and maximize the effectiveness, efficiency, an…”
Background(2003) · CRC Press eBooks · doi:10.1201/9780367804787 · Cited by 1,227
Types of Unintended Consequences Related to Computerized Provider Order Entry
Campbell, E. M., Sittig, D. F., Ash, J. S., Guappone, K. P., & Dykstra, R. H. (2006) · Journal of the American Medical Informatics Association · doi:10.1197/jamia.m2042 · Cited by 823
Harrison, M. I., Koppel, R., & Bar-Lev, S. (2007) · Journal of the American Medical Informatics Association · doi:10.1197/jamia.m2384 · Cited by 691
Measuring errors and adverse events in health care
Thomas, E. J., & Petersen, L. A. (2003) · Journal of General Internal Medicine · doi:10.1046/j.1525-1497.2003.20147.x · Cited by 456 · cited 1×
“17 To overcome some of these disadvantages, we electronically searched for similar types of errors.”
MethodSelf-citationHarnessing the Power of Default Options to Improve Health Care
Halpern, S. D., Ubel, P. A., & Asch, D. A. (2007) · New England Journal of Medicine · doi:10.1056/nejmsb071595 · Cited by 370 · cited 1×
“While default options may improve care in some settings, 22 our results suggest a need for more careful consideration before their use.”
Background
Flagged first, then by citations
1 of the 29 references couldn’t be matched to a known paper.
Research works printed but not linked: 2
- [15]Joint Commission on Accreditation of Healthcare Organizations Sentinel event statistics, March 31, 2006 Joint Commission on Accreditation of Healthcare Organizations 2005 Available at: URL: http://www.jointcommission.org/NR/rdonlyres/FA465646-5F5F-4543-AC8F-E8AF6571E372/0/root_cause_se.jpg 17139928
- [26]Schoeffel R The concept of product usability ISO Bulletin 34[3], 6–7 2003 Ref Type: Generic
Cited by
Sorted by citations
Types and Origins of Diagnostic Errors in Primary Care Settings
Singh, H., Giardina, T. D., Meyer, A. N. D., Forjuoh, S. N., Reis, M. D., & Thomas, E. J. (2013) · JAMA Internal Medicine · doi:10.1001/jamainternmed.2013.2777 · Cited by 559
Self-citationHealth IT and Patient Safety: Building Safer Systems for Better Care
Chou, D. (2012) · JAMA · doi:10.1001/jama.308.21.2282-a · Cited by 496
Kim, M. O., Coiera, E., & Magrabi, F. (2017) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocw154 · Cited by 263
“…(2005)42 548 7 Mortality increased from 2.8% to 6.7%, no further details provided Nanji et al. (2011)40 466 35 N/A Palchuk et al. (2010)39 470 84 N/A Singh et al. (2009)29 558a 71 N/A Walsh et al. (2006)38 20 50 N/A 50 Westbrook et al. (2012)51 and (2013)41 493 2 N/A aErrors analyzed for…”
BackgroundInfluentialAn analysis of electronic health record-related patient safety concerns
Meeks, D. W., Smith, M. W., Taylor, L., Sittig, D. F., Scott, J. M., & Singh, H. (2014) · Journal of the American Medical Informatics Association · doi:10.1136/amiajnl-2013-002578 · Cited by 207
Self-citationElectronic health records and national patient-safety goals
Sittig, D. F., & Singh, H. (2012) · New England Journal of Medicine · doi:10.1056/nejmsb1205420 · Cited by 204
Self-citation
Metadata
- Authors
- Singh, H., Mani, S., Espadas, D., Petersen, N., Franklin, V., & Petersen, L. A.
- Affiliations
- Michael E. DeBakey VA Medical Center (US)
- Venue
- Archives of Internal Medicine
- Publisher
- American Medical Association (AMA)
- Published
- 2009-05-25
- Volume
- 169
- Issue
- 10
- Pages
- 982
- ISSN
- 0003-9926 (ISSN-L)
- PMC
- PMC2919338
- OpenAlex
- W2077178507
- Semantic Scholar
- ec2c80787b615a3670292bc6644dbb7d00e3d068
- Cited by
- 104
- References
- 29
- Citations by year
- 2026: 1 · 2024: 1 · 2022: 1 · 2021: 8 · 2020: 3 · 2019: 2 · 2018: 7 · 2017: 5 · 2016: 7 · 2015: 13 · 2014: 9 · 2013: 11 · 2012: 7
- FWCI
- 25.33
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Archives of Internal Medicine (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Cancer Institute (K23CA125585)
- Topics
- Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Patient Safety and Medication Errors
- Health Sciences › Medicine › Geriatrics and Gerontology › Pharmaceutical Practices and Patient Outcomes
- Keywords
- computerized physician order entry, prescribing errors, data inconsistency, structured templates, medication errors, drug dosage errors, inpatient prescriptions, surgical subspecialties, drug safety
- MeSH terms
- Group Practice, Humans, Medication Errors, Drug Prescriptions, Prospective Studies, Quality Assurance, Health Care, Clinical Pharmacy Information Systems, Medical Order Entry Systems
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
A language model drew the claims from the paper on 2026-10-07, under version 3 of the claim definition (model deepseek-v4.1-flash, prompt extract-v3).
A second model labelled each claim on 2026-10-07 (model jev-1.13-20260917, definition revision gold-guideline-v0.2).
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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