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Study: Half of Medication Errors Involve CPOE Systems

Analysts find HIT-related mistakes at every step of medication-use process

In 2009, under the Health Information Technology for Economic and Clinical Health (HITECH) act, billions of dollars were offered in incentives for health care providers to adopt electronic health records (EHRs). In addition, health information technologies (HITs) targeting each point of the medication-use process were developed to reduce the likelihood of errors reaching the patient. These technologies included computerized prescriber order entry (CPOE) systems, pharmacy information systems, and automated dispensing cabinets. Unfortunately, the introduction of HIT to improve patient safety has led to new, unforeseen types of errors, according to a new study from the Pennsylvania Patient Safety Authority.

In 2015, a new question was added to the Pennsylvania Patient Safety Reporting System (PA-PSRS) reporting form: “Did Health IT cause or contribute to this event?” The findings indicated that HIT-related errors occurred during every step of the medication-use process and that 69% of these errors (615 of 889) reached patients. Only eight errors (0.9%), however, resulted in patient harm.

Further, analysts found that CPOE systems were a contributing factor in 50% (448 of 889) of reported error events. The pharmacy system and the electronic medication administration record (eMAR) were each mentioned in slightly more than a quarter of the event reports. Other EHR components, including the clinical documentation system and the clinical decision support system, were implicated in 14% of events.

The CPOE system was cited most often as an HIT component that contributed to the top three types of error event. The system contributed to more than half of dose omissions, extra doses, and wrong dose/overdosage events. The pharmacy system and the eMAR were also frequently involved in these events. With respect to ergonomics, data-entry or selection errors accounted for almost half (48.9% [219 of 448]) of all CPOE events.

Surprisingly, the analysts found that the point in the medication-use process where errors occur today is very similar to where they occurred in 1993, before the widespread implementation of HIT. In 1995, Bates and colleagues reported in JAMA that most errors occurred during the ordering (49%) and administration (26%) stages, which is what was found in the new analysis.

Source: Pennsylvania Patient Safety Advisory; March 2017.

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