Computerized Prescriber Order Entry and Opportunities for Medication Errors

Jozefczyk, Kenneth G.; Kennedy, W. Klugh; Lin, Miranda; Achatz, Julie; Glass, Maresa; Eidam, W. Susie; Melroy, Michael J

doi:10.1177/0897190012465982

Cited by 22 publications

(16 citation statements)

References 7 publications

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“…Knowledge about routines related to documenting drug related information in the journal appeared to be another issue. At the same time it is important to note that these systems are likely to reduce mediation errors relating to prescriptions [19,20]. …”

Section: Discussionmentioning

confidence: 99%

Medication errors related to transdermal opioid patches: lessons from a regional incident reporting system

Lövborg

Holmlund

Hägg

2014

BMC Pharmacol Toxicol

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ObjectiveA few cases of adverse reactions linked to erroneous use of transdermal opioid patches have been reported in the literature. The aim of this study was to describe and characterize medication errors (MEs) associated with use of transdermal fentanyl and buprenorphine.MethodsAll events concerning transdermal opioid patches reported between 2004 and 2011 to a regional incident reporting system and assessed as MEs were scrutinized and characterized. MEs were defined as “a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient”.ResultsIn the study 151 MEs were identified. The three most common error types were wrong administration time 67 (44%), wrong dose 34 (23%), and omission of dose 20 (13%). Of all MEs, 118 (78%) occurred in the administration stage of the medication process. Harm was reported in 26 (17%) of the included cases, of which 2 (1%) were regarded as serious harm (nausea/vomiting and respiratory depression). Pain was the most common adverse reaction reported.ConclusionsOf the reported MEs related to transdermal fentanyl and buprenorphine, most occurred during administration. Improved routines to ascertain correct and timely administration and educational interventions to reduce MEs for these drugs are warranted.

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Section: Discussionmentioning

confidence: 99%

Medication errors related to transdermal opioid patches: lessons from a regional incident reporting system

Lövborg

Holmlund

Hägg

2014

BMC Pharmacol Toxicol

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“…Electronic medication prescribing [51][52][53][54][55] Clinical decision support alone (n = 2) Electronic tool to verify parenteral nutrition orders [34][35] Computer programmes (n = 8)…”

Section: Intervention Type Example Of Intervention Referencesmentioning

confidence: 99%

Interventions to reduce medication errors in neonatal care: a systematic review

Nguyen

Mosel

Grzeskowiak

2017

Therapeutic Advances in Drug Safety

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Background: Medication errors represent a significant but often preventable cause of morbidity and mortality in neonates. The objective of this systematic review was to determine the effectiveness of interventions to reduce neonatal medication errors. Methods: A systematic review was undertaken of all comparative and noncomparative studies published in any language, identified from searches of PubMed and EMBASE and referencelist checking. Eligible studies were those investigating the impact of any medication safety interventions aimed at reducing medication errors in neonates in the hospital setting. Results: A total of 102 studies were identified that met the inclusion criteria, including 86 comparative and 16 noncomparative studies. Medication safety interventions were classified into six themes: technology (n = 38; e.g. electronic prescribing), organizational (n = 16; e.g. guidelines, policies, and procedures), personnel (n = 13; e.g. staff education), pharmacy (n = 9; e.g. clinical pharmacy service), hazard and risk analysis (n = 8; e.g. error detection tools), and multifactorial (n = 18; e.g. any combination of previous interventions). Significant variability was evident across all included studies, with differences in intervention strategies, trial methods, types of medication errors evaluated, and how medication errors were identified and evaluated. Most studies demonstrated an appreciable risk of bias. The vast majority of studies (>90%) demonstrated a reduction in medication errors. A similar median reduction of 50-70% in medication errors was evident across studies included within each of the identified themes, but findings varied considerably from a 16% increase in medication errors to a 100% reduction in medication errors. Conclusion: While neonatal medication errors can be reduced through multiple interventions aimed at improving the medication use process, no single intervention appeared clearly superior. Further research is required to evaluate the relative cost-effectiveness of the various medication safety interventions to facilitate decisions regarding uptake and implementation into clinical practice.

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“…It is clear from the current study that for both groups of infants there has been an improvement in accuracy of recording the birth weight and that this has been greater for those <1000 g than those ≥1000 g. This is likely to be due to progressive improvements in nurse training and to some degree the greater involvement by nurses in dose checking and non-medical prescribing10 over the last decade increasing their understanding of the importance of the accuracy of weight in drug dose calculation 9. The absence of any step change in this reflects a steady group behavioural change with increasing attention to accurate weight measurement.…”

Section: Discussionmentioning

confidence: 75%

“…Many drug errors are due to poor manual calculation and there is evidence that the use of computerised prescribing can reduce errors significantly 9. All neonatal prescribing software packages rely on the accuracy of the measured weight.…”

Section: Discussionmentioning

confidence: 99%

Rounding of birth weights in a neonatal intensive care unit over 20 years: an analysis of a large cohort study

Emmerson

Roberts

2013

BMJ Open

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ObjectiveTo determine the frequency of birth weight digit preference for infants admitted to a large neonatal intensive care unit (NICU), the scale of rounding and its dependence on birth weight, and time and the impact on prescribing accuracy.DesignA consecutive cohort of birth weights extracted retrospectively from a single clinical database.Setting and participantsBirth weights from 9170 inborn infants recorded on an electronic prescribing database admitted to NICU over 20 years.Statistical approachData are presented for the frequency of each of the possible pairs of final digits. A statistical model of digit preference assuming rounding is used to quantify the proportions rounding to specific accuracy levels. These proportions are compared between those <1000 g and those above and over the 20-year time period.ResultsFrom a population of 9170 infants admitted over 20 years, there was a highly statistically significant digit bias with an increased prevalence of multiples of 100 (p<0.0001), 50 (p=0.007), 20 (p<0.0001), 10 (p<0.0001), 5 (p<0.0001) and 2 (p=0.0005). There was clear evidence of a reduced 100 g digit bias for infants 500 and 1000 g (0%) compared with those between 1000 and 4500 g (3.7%). The maximum birth weight error due to digit bias for all infants was 5%. There was clear evidence of an improvement in accuracy over 20 years.ConclusionsDigit bias in birth weights over 20 years in a tertiary NICU is highly significant at the 100, 50, 20, 10, 5 and 2-digit levels. There has been a substantial improvement in the accuracy of birth weight measurements over 20 years. The likely maximum error due to birth weight digit bias is 5% and is within an acceptable tolerance for drug dosing even at very low birth weights.

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Computerized Prescriber Order Entry and Opportunities for Medication Errors

Abstract: The implementation of CPOE was associated with a reduction in OEs in the prescribing phase or order entry phase of the medication-use process.

Cited by 22 publications

References 7 publications

Medication errors related to transdermal opioid patches: lessons from a regional incident reporting system

Medication errors related to transdermal opioid patches: lessons from a regional incident reporting system

Interventions to reduce medication errors in neonatal care: a systematic review

Rounding of birth weights in a neonatal intensive care unit over 20 years: an analysis of a large cohort study

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