Implementation of a custom alert to prevent medication-timing errors associated with computerized prescriber order entry

Purpose: The implementation of a custom alert to prevent medication-timing errors associated with the use of a computerized prescriber order-entry (CPOE) system is described.

Methods: In early 2013, Virginia Mason Medical Center began work to modify the CPOE system to make it impossible for a medication-timing error to occur. A visual control, a custom alert that forced prescribers to "self-inspect with pause" (a soft-stop override) before signing an order that may result in a medication-timing error, was developed. The prescriber could choose to modify the order to skip the next dose or change the start date or time of the order, cancel the order, or continue without altering the order. The custom alert was designed to fire only for medications that are administered once or twice daily. The effectiveness of the intervention was evaluated with interrupted time series before-and-after analysis of medication-timing errors. Outcomes measured included the proportion of errors that were corrected by the prescriber before signing the order and the number of medication-timing errors that reached patients.

Results: The proportion of orders where a prescriber modified the order as a result of the alert increased from 12% before the intervention to 29% postintervention (p > 0.001), and this percentage continued to increase at five months postintervention (p < 0.001). The percentage of medication-timing errors that reached the patient decreased by 50% in the postintervention period.

Conclusion: Medication-timing errors associated with the use of a CPOE system were corrected through implementation of a customized alert.