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Background Numerous national and international authorities have advised against the use of certain prescribing abbreviations due to their risk of misinterpretation. Aim To evaluate an intervention to reduce the use of error‐prone prescribing abbreviations in the emergency department (ED). Method The intervention consisted of education sessions as part of ED medical and nursing orientation programs, distribution of name badge sized cards summarising the information and placement of posters in the ED. All medication and fluid charts present in the ED at one randomly selected time each day were screened over consecutive days. Patients with at least one medication or fluid prescribed were included. Error‐prone abbreviations were classified as of major, moderate or minor significance. Pre‐intervention data on abbreviation usage guided the content of the intervention. Results 166 patients were included pre‐intervention and a further 166 patients post‐intervention. The overall rate of error‐prone abbreviation use per 100 prescriptions declined from 31.8 pre‐intervention to 18.7 post‐intervention (difference in rates 13.1; 95%CI 8.8–17.4; p < 0.001). The rate of use of major significance error‐prone abbreviations per 100 prescriptions decreased from 5.8 pre‐intervention to 2.3 post‐intervention (difference in rates 3.5; 95%CI 1.8–5.2; p < 0.001). Conclusion The intervention resulted in a significant reduction in the use of error‐prone abbreviations in the ED. Implementing this intervention hospital‐wide should have a further impact as ward‐based doctors also prescribe medications in the ED.

The aim of the present study was to identify and quantify medication errors reportedly related to electronic medication management systems (eMMS) and those considered likely to occur more frequently with eMMS. This included developing a new classification system relevant to eMMS errors. Eight Victorian hospitals with eMMS participated in a retrospective audit of reported medication incidents from their incident reporting databases between May and July 2014. Site-appointed project officers submitted deidentified incidents they deemed new or likely to occur more frequently due to eMMS, together with the Incident Severity Rating (ISR). The authors reviewed and classified incidents. There were 5826 medication-related incidents reported. In total, 93 (47 prescribing errors, 46 administration errors) were identified as new or potentially related to eMMS. Only one ISR2 (moderate) and no ISR1 (severe or death) errors were reported, so harm to patients in this 3-month period was minimal. The most commonly reported error types were 'human factors' and 'unfamiliarity or training' (70%) and 'cross-encounter or hybrid system errors' (22%). Although the results suggest that the errors reported were of low severity, organisations must remain vigilant to the risk of new errors and avoid the assumption that eMMS is the panacea to all medication error issues. eMMS have been shown to reduce some types of medication errors, but it has been reported that some new medication errors have been identified and some are likely to occur more frequently with eMMS. There are few published Australian studies that have reported on medication error types that are likely to occur more frequently with eMMS in more than one organisation and that include administration and prescribing errors. This paper includes a new simple classification system for eMMS that is useful and outlines the most commonly reported incident types and can inform organisations and vendors on possible eMMS improvements. The paper suggests a new classification system for eMMS medication errors. The results of the present study will highlight to organisations the need for ongoing review of system design, refinement of workflow issues, staff education and training and reporting and monitoring of errors.