Computerized POE substantially decreased the rate of non-missed-dose medication errors. A major reduction in errors was achieved with the initial version of the system, and further reductions were found with addition of decision support features.

Study Objective: To evaluate the potential ability of computerized information systems (KS) to identify and prevent adverse events in medical patients.Design: Clinical descriptions of all 133 adverse events identified through chart review for a cohort of 3,138 medical patients were evaluated by two reviewers. Measurements:For each adverse event, three hierarchical levels of IS sophistication were considered: Level l-demographics, results for all diagnostic tests, and current medications would be available on-line; Level 2-all orders would be entered on-line by physicians; and Level 3-additional clinical data, such as automated problem lists, would be available on-line. Potential for event identificationand potential for event prevention were scored by each reviewer according to two distinct sets of event monitors.Results: Of all the adverse events, 53% were judged identifiable using Level 1 information, 58% were judged identifiable using Level 2 information, and 89% were judged identifiable using Level 3 information.The highest-yield event monitors for identifying adverse events were "panic" laboratory results, unexpected transfer to an intensive care unit, and hospital-incurred trauma. With information from Levels 1, 2, and 3, 5%, 13%, and 23% of the adverse events, respectively, were judged preventable. For preventing these adverse events, guided-dose algorithms, drug-laboratory checks, and drug-patient characteristic checks held the most potential.

Purpose The true extent of drug diversion practices in acute health care settings is unknown. Drug abuse by professional staff may result in jeopardized patient safety discredited organizational reputations, compromised financial outcomes, and endangered community trust. Yet, limitations in reporting drug diversion behaviors by health care professionals precludes quantification of the scope of these practices in nurses, physicians, and pharmacists. This manuscript describes one institution's efforts to monitor drug diversion with the implementation of a novel pharmacy-based role, the Pharmacy Compliance Officer (PCO). Methods Nearly 5 years of PCO experience will be identified and organizational drug diversion methods will be delineated. Common profiles of professional drug diverters in acute care will be depicted with a review of the literature on pharmacist, nurse, and physician drug dependency characteristics. The collaborative process between the PCO and Nursing Directors will be described with particular emphasis on options for validating drug diversion and confronting employees with evidence. Exemplars of drug diversion by professional staff will be highlighted with the use of two case studies. Cost implications will be discussed as well. Results The PCO has assisted with the identification of staff at risk, and responsible for, drug diversion. Implementation of this novel role has facilitated the early recognition of staff with active substance abuse disorders. Our relationship with the State Boards of Pharmacy and Nursing has been enhanced due to this proactive approach to recognizing drug diversion practices in professional staff. Conclusion This contemporary strategy has the potential for replication, particularly in large, diverse, urban, acute care settings, where drug volume is high, information systems are frequently complex; hence, identification of drug-diverting professionals is circuitous.