Free text as part of Electronic Health Record orders: Context or concern? (23 July 2024)

Summary

When placing orders into the electronic health record (EHR), prescribers often use free-text information to complement the order. However, the use of these free-text fields can result in patient safety issues. The objective of this study was to develop a deeper understanding of the conditions under which free-text information, or special instructions, are used in the EHR and the patient safety issues associated with their use, through an analysis of patient safety event (PSE) reports.

Special instructions are frequently used to provide additional context about medication orders and laboratory and radiology procedures and are often intended for nurses and pharmacists. However, these instructions can result in errors and may cause patient harm. Based on our analysis, we provide EHR design strategies and policies and protocols to address patient safety issues associated with free text to enable safer and more resilient care delivery.

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