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J Am Med Inform Assoc. 2016 Sep 27. pii: ocw125. doi: 10.1093/jamia/ocw125. [Epub ahead of print]

Computerized prescriber order entry-related patient safety reports: analysis of 2522 medication errors.

Author information

  • 1Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA MCPHS University, Boston.
  • 2Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.
  • 3Partners HealthCare, Information Systems, Wellesley, Massachusetts.
  • 4Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA Harvard Medical School, Boston.
  • 5University of Illinois at Chicago, Chicago, Illinois, USA.
  • 6University of Pennsylvania, Philadelphia, USA.
  • 7Atrius Health, Boston.
  • 8Columbia University Medical Center, New York, New York, USA.
  • 9Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA.
  • 10Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA Partners HealthCare, Information Systems, Wellesley, Massachusetts Harvard Medical School, Boston Harvard School of Public Health, Boston.
  • 11Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA Harvard Medical School, Boston gschiff@partners.org.

Abstract

OBJECTIVE:

To examine medication errors potentially related to computerized prescriber order entry (CPOE) and refine a previously published taxonomy to classify them.

MATERIALS AND METHODS:

We reviewed all patient safety medication reports that occurred in the medication ordering phase from 6 sites participating in a United States Food and Drug Administration-sponsored project examining CPOE safety. Two pharmacists independently reviewed each report to confirm whether the error occurred in the ordering/prescribing phase and was related to CPOE. For those related to CPOE, we assessed whether CPOE facilitated (actively contributed to) the error or failed to prevent the error (did not directly cause it, but optimal systems could have potentially prevented it). A previously developed taxonomy was iteratively refined to classify the reports.

RESULTS:

Of 2522 medication error reports, 1308 (51.9%) were related to CPOE. Of these, CPOE facilitated the error in 171 (13.1%) and potentially could have prevented the error in 1137 (86.9%). The most frequent categories of "what happened to the patient" were delays in medication reaching the patient, potentially receiving duplicate drugs, or receiving a higher dose than indicated. The most frequent categories for "what happened in CPOE" included orders not routed to or received at the intended location, wrong dose ordered, and duplicate orders. Variations were seen in the format, categorization, and quality of reports, resulting in error causation being assignable in only 403 instances (31%).

DISCUSSION AND CONCLUSION:

Errors related to CPOE commonly involved transmission errors, erroneous dosing, and duplicate orders. More standardized safety reporting using a common taxonomy could help health care systems and vendors learn and implement prevention strategies.

KEYWORDS:

computerized provider order entry; electronic prescribing; health information technology; medication errors; medication safety

PMID:
27678459
DOI:
10.1093/jamia/ocw125
[PubMed - as supplied by publisher]
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