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J Am Med Inform Assoc. 2007 Nov-Dec;14(6):756-64. Epub 2007 Aug 21.

Medication administration discrepancies persist despite electronic ordering.

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  • 1Department of Biomedical Informatics, Vanderbilt University Medical Center, 2525 West End Avenue, Nashville, TN 37203, USA. fern.fitzhenry@vanderbilt.edu


Background Up to 38% of inpatient medication errors occur at the administration stage. Although they reduce prescribing errors, computerized provider order entry (CPOE) systems do not prevent administration errors or timing discrepancies. This study determined the degree to which CPOE medication orders matched actual dose administration times. METHODS At a 658-bed academic hospital with CPOE but lacking electronic medication administration charting, authors randomly selected adult patients with eligible medication orders from historical 1999-2003 CPOE log files. Retrospective manual chart audits compared expected (from CPOE) and actual timing of medication administrations. Outcomes included: dose omissions, median lag times between ordered and charted administrations, unauthorized doses, wrong dose errors, and the rate of nurses' medication schedule shifting. RESULTS Dose omissions occurred in 756 of 6019 (12.6%) audited administration opportunities; only 313 of the omissions (5.2% of opportunities) were unexplained. Wrong doses and unexpected doses occurred for 0.1% and 0.7% of opportunities, respectively. Median lag from expected first dose to actual charted administration time was 27 minutes (IQR 0-127). Nursing staff shifted from ordered to alternate administration schedules for 10.7% of regularly scheduled recurring medication orders. Chart review identified reasons for dose omissions, delays, and dose shifting. CONCLUSION Inpatient CPOE orders are legible and conveyed electronically to nurses and the pharmacy. Nonetheless, ward-based medication administrations do not consistently occur as ordered. Medication administration discrepancies are likely to persist even after implementing CPOE and bar-coded medication administration unless recommended interventions are made to address issues such as determining the true urgency of medication administration, avoiding overlapping duplicative medication orders, and developing a safe means for shifting dosing schedules.

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