In a before-and-after study, Johanna Westbrook and colleagues evaluate the change in prescribing error rates after the introduction of two commercial electronic prescribing systems in two Australian hospitals.

ObjectivesTo (i) compare medication errors identified at audit and observation with medication incident reports; (ii) identify differences between two hospitals in incident report frequency and medication error rates; (iii) identify prescribing error detection rates by staff.DesignAudit of 3291patient records at two hospitals to identify prescribing errors and evidence of their detection by staff. Medication administration errors were identified from a direct observational study of 180 nurses administering 7451 medications. Severity of errors was classified. Those likely to lead to patient harm were categorized as ‘clinically important’.SettingTwo major academic teaching hospitals in Sydney, Australia.Main Outcome MeasuresRates of medication errors identified from audit and from direct observation were compared with reported medication incident reports.ResultsA total of 12 567 prescribing errors were identified at audit. Of these 1.2/1000 errors (95% CI: 0.6–1.8) had incident reports. Clinically important prescribing errors (n = 539) were detected by staff at a rate of 218.9/1000 (95% CI: 184.0–253.8), but only 13.0/1000 (95% CI: 3.4–22.5) were reported. 78.1% (n = 421) of clinically important prescribing errors were not detected. A total of 2043 drug administrations (27.4%; 95% CI: 26.4–28.4%) contained ≥1 errors; none had an incident report. Hospital A had a higher frequency of incident reports than Hospital B, but a lower rate of errors at audit.ConclusionsPrescribing errors with the potential to cause harm frequently go undetected. Reported incidents do not reflect the profile of medication errors which occur in hospitals or the underlying rates. This demonstrates the inaccuracy of using incident frequency to compare patient risk or quality performance within or across hospitals. New approaches including data mining of electronic clinical information systems are required to support more effective medication error detection and mitigation.

ObjectivesTo compare the manifestations, mechanisms, and rates of system-related errors associated with two electronic prescribing systems (e-PS). To determine if the rate of system-related prescribing errors is greater than the rate of errors prevented.MethodsAudit of 629 inpatient admissions at two hospitals in Sydney, Australia using the CSC MedChart and Cerner Millennium e-PS. System related errors were classified by manifestation (eg, wrong dose), mechanism, and severity. A mechanism typology comprised errors made: selecting items from drop-down menus; constructing orders; editing orders; or failing to complete new e-PS tasks. Proportions and rates of errors by manifestation, mechanism, and e-PS were calculated.Results42.4% (n=493) of 1164 prescribing errors were system-related (78/100 admissions). This result did not differ by e-PS (MedChart 42.6% (95% CI 39.1 to 46.1); Cerner 41.9% (37.1 to 46.8)). For 13.4% (n=66) of system-related errors there was evidence that the error was detected prior to study audit. 27.4% (n=135) of system-related errors manifested as timing errors and 22.5% (n=111) wrong drug strength errors. Selection errors accounted for 43.4% (34.2/100 admissions), editing errors 21.1% (16.5/100 admissions), and failure to complete new e-PS tasks 32.0% (32.0/100 admissions). MedChart generated more selection errors (OR=4.17; p=0.00002) but fewer new task failures (OR=0.37; p=0.003) relative to the Cerner e-PS. The two systems prevented significantly more errors than they generated (220/100 admissions (95% CI 180 to 261) vs 78 (95% CI 66 to 91)).ConclusionsSystem-related errors are frequent, yet few are detected. e-PS require new tasks of prescribers, creating additional cognitive load and error opportunities. Dual classification, by manifestation and mechanism, allowed identification of design features which increase risk and potential solutions. e-PS designs with fewer drop-down menu selections may reduce error risk.

Background: Implementation of electronic medication management systems (eMMS) are advocated to reduce medication errors, improve patient safety and impact on hospital pharmacists' work patterns. Aims: To quantify hospital pharmacists' distribution of their time and to identify differences in work patterns on wards with and without eMMS. Method: An observational time and motion study was conducted at a major Sydney teaching hospital. 8 pharmacists (3 on wards with eMMS, 5 on wards without eMMS) were observed on their wards for 37 hours. Distribution of tasks across work categories, mean task times, tasks performed with others and tasks using information tools, were calculated and compared between wards with and without eMMS. Results: Medication chart review was the most frequently performed task on both ward types. Pharmacists on eMMS wards had lower rates of interruptions (1/19.2 min vs 1/13.7 min) and multi-tasking (2.4% vs 8.7%) than non-eMMS wards. On eMMS wards, review activities were more frequent and faster, fewer 'in-transit' tasks occurred and more work was completed alone compared to non-eMMS wards. Patient care tasks took longer but occurred less often on eMMS wards. Pharmacists on eMMS wards spent more time clarifying medication orders but did it less often than pharmacists on non-eMMS wards. Conclusion: Pharmacists' work patterns in terms of task frequency, duration and location was different on the two ward types. Differences may be attributable to eMMS allowing easy and speedy access to information for reviews; shift away from the bedside to a computer terminal reducing tasks in-transit, interruptions and contact with patients and others; and improved clarity of medication orders reducing queries. J Pharm Pract Res 2010; 40: 106-10.

BackgroundAn electronic venous thromboembolism (VTE) prophylaxis clinical decision support (CDS) tool was implemented in an electronic medication management system at an Australian tertiary teaching hospital. The VTE CDS had not been clinically validated nor widely adopted.AimThis study evaluated the effectiveness of the VTE CDS for improving risk‐appropriate prescribing of VTE prophylaxis, a peer‐to‐peer strategy for improving adoption of the VTE CDS and the effects of the strategy on VTE risk assessment documentation, risk‐appropriate prophylaxis prescribing rate and user acceptability of the VTE CDS.MethodsNominated junior medical officers were trained to educate and promote the use of the VTE CDS to target colleagues over 6 weeks. Pre‐ and postintervention audits of VTE risk assessment and prophylaxis prescribing were conducted. A user acceptance survey was distributed.ResultsAnalysis of pre‐ and postintervention audit data (n = 198 for each) revealed no significant differences in rates of VTE CDS adoption or risk‐appropriate VTE prophylaxis prescribed. More patients had risk‐appropriate prophylaxis prescribed when the VTE CDS was used (90%; 63/70) than when it was not used (71.5% (233/326); p = 0.001). Documented evidence of VTE risk assessment increased significantly from 51.5% (102/198) to 68.2% (135/198) following the intervention (p < 0.001). Most survey responses were favourable towards VTE CDS usability despite limitations.ConclusionPeer‐to‐peer promotion was unsuccessful in improving VTE CDS adoption in this study. Findings suggest VTE CDS use is associated with more appropriate VTE prophylaxis prescribing decisions and may improve risk assessment documentation. Future studies should examine strategies to sustainably improve adoption of VTE CDS and patient outcomes.