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PSNet: Patient Safety Network
Journal Article

Design and Implementation of a Tool for Pharmacists to Register Potential Errors in Prescribed Medication.

Frid S, Zapico V, Mansilla A, et al. Studies in health technology and informatics. 2019;264:581-585.

Clinical provider order entry (CPOE) and clinical decision support systems  (CDSS) are intended to enhance medication safety by reducing errors associated with prescription drugs. This study evaluated a tool allowing pharmacists to record errors or near misses, such as medication omission or unjustified medication stops, and communicate those events to the provider. Although only 29% of physicians accepted the pharmacist’s recommendations, these communicated events led to the provider following 112 recommended changes, which was an acceptance rate of 58%.