Pueyo-López C, Sánchez-Cuervo M, Vélez-Díaz-Pallarés M, et al. J Oncol Pharm Pract. 2021;27:1588-1595.
Researchers in this study used healthcare failure mode and effect analysis (HFMEA) to identify and reduce errors during chemotherapy preparation. Nine potential failure modes were identified – wrong label, drug, dose, solvent, or volume; non-sterile preparation; incomplete control; improper packaging or labeling, and; break or spill – and the potential causes and effects. Potential approaches to reduce these failure modes include updating the Standard Operating Procedures (SOPs), implementing a bar code system, and using a weight-based control system.
Abraham J, Galanter WL, Touchette DR, et al. J Am Med Inform Assoc. 2021;18:86-94.
Computerized provider order entry (CPOE) can prevent prescribing errors. In this study, researchers assessed voided medication orders to characterize medication ordering errors. Duplicate orders and improperly composed (wrong route, dose, strength, schedule) orders were most common and three-quarters were intercepted prior to administration. Risk factors for medication errors were multifactorial, arising from technological, cognitive, environmental, social, and organizational-level factors.
Using root cause analysis data submitted to the Veterans Affairs (VA) National Center for Patient Safety from 2013 to 2018, this study analyzed health information technology (HIT)-related outpatient diagnostic delays to identify common safety concerns. The study identified five high-risk areas for diagnostic delays involving HIT: managing electronic health record inbox notifications and communications, clinicians gathering key diagnostic information, technical problems, data entry problems, and failure of a system to track test results.
Fortman E, Hettinger AZ, Howe JL, et al. J Am Med Inform Asso. 2020.
Physicians from different health systems using two computerized provider order entry (CPOE) systems participated in simulated patient scenarios using eye movement recordings to determine whether the physician looked at patient-identifying information when placing orders. The rate of patient identification overall was 62%, but the rate varied by CPOE system. An expert panel identified three potential reasons for this variation – visual clutter and information density, the number of charts open at any given time, and the importance placed on patient identification verification by institutions.
Adelman JS, Applebaum JR, Schechter CB, et al. JAMA. 2019;321:1780-1787.
Having multiple patient records open in the electronic health record increases the potential risk of wrong-patient actions. This randomized trial tested two different electronic health record configurations: one allowed up to four patient records to be open at a time, and the other allowed only one to be open. Among the 3356 clinicians with nearly 4.5 million order sessions, there were no significant differences in wrong-patient orders. However, the investigators noted that clinicians in the multiple records group placed most orders with just one record open. A post hoc analysis determined that the rate of errors increased when orders were placed with multiple records open. A related editorial highlights the tradeoffs between safety and efficiency and argues for examining the context of the two configurations, including throughput and clinician satisfaction. A previous PSNet perspective discussed assessing and improving the safety of electronic health records.
Yang Y, Ward-Charlerie S, Dhavle AA, et al. J Manag Care Spec Pharm. 2018;24:691-699.
Electronic prescribing has yielded unequivocal improvement in outpatient medication safety. However, electronic health record prescribing infrastructure differs substantially, which creates safety hazards when prescribers transmit information to pharmacies. Researchers examined 25,000 prescriptions sent to a retail pharmacy chain and described variation in the Sig line—prescriber instructions for how a patient should use a medication. The 501 separate electronic prescribing systems generated 832 different ways to communicate the simple instruction: "Take 1 tablet by mouth daily." About 10% of prescriptions posed a potential safety hazard. An AHRQ tool provides standard language to clarify directions for patients regarding how to take their medications. A previous WebM&M commentary discussed strategies for pharmacies, clinics, and providers to mitigate the risk of patient confusion.
Rider BB, Gaunt MJ, Grissinger M. PA-PSRS Patient Saf Advis. September 2016;13:81-91.
Prescribing errors can have harmful results. Analyzing prescribing error reports submitted over a 12- year period, this article recommends strategies to reduce risks associated with prescribing, including use of computerized provider order entry systems and standard order sets.
Brown CL, Mulcaster HL, Triffitt KL, et al. Journal of the American Medical Informatics Association. 2016.
The use of computerized provider order entry (CPOE) systems, in which clinicians place orders for tests, labs, and medications electronically, has grown rapidly in both inpatient and outpatient settings. Although research has shown that implementation of CPOE can reduce prescribing errors in both inpatient and outpatient settings, additional studies have found that errors continue to occur. In this systematic review, researchers identified multiple factors linked to CPOE prescribing errors, including flaws in functional design and underlying clinical decision support systems, as well as insufficient system flexibility leading to user workarounds. The authors suggest that further consideration must be given to human factors design principles. A recent Annual Perspective highlighted some of the ongoing challenges associated with CPOE.
Brigham and Women's Hospital, Harvard Medical School, Partners HealthCare. Silver Spring, MD: US Food and Drug Administration; December 15, 2015.
Electronic prescribing, considered an opportunity to reduce medication errors, has been linked to problems unique to technology use. This white paper discusses the results of a multi-hospital effort to develop a process and tools to collect and analyze data related to search, display, and workflow issues associated with computerized provider order entry. The authors offer recommendations to enhance the safety of electronic prescribing, including standardizing drug names, minimizing the number of alerts, and designing better search functions.
Nelson CE, Selbst SM. Pediatr Emerg Care. 2015;31:368-72.
According to this retrospective chart review study, clinically significant prescription errors continued to occur at an alarming rate in a pediatric emergency department, despite the introduction of computerized provider order entry. Emergency medicine residents made more prescribing errors than pediatric residents.
Schiff GD, Amato MG, Eguale T, et al. BMJ Qual Saf. 2015;24:264-71.
This study used a two-stage approach to analyze the effectiveness of computerized provider order entry (CPOE) at preventing medication errors in real-world settings. The investigators analyzed data from the MEDMARX database in order to identify the types of medication errors caused by computerized order entry. From these data, the researchers developed 21 examples of problematic orders and tested whether they could be entered in a range of commercial CPOE systems. The majority of orders were entered successfully and quickly, without the CPOE system generating any alerts or requiring clinicians to use only minor workarounds to enter the order. Even when the CPOE system did generate an alert, these could generally be overridden by clinicians without changing the order. The study findings mirror those of a prior simulation study and highlight the importance of real-world usability testing for health information technology. Although CPOE systems have been shown to reduce prescribing errors, this study's results indicate that the safety benefits of CPOE may not be achieved without careful implementation and ongoing evaluation.
Carayon P, Wetterneck TB, Cartmill R, et al. BMJ Qual Saf. 2014;23:56-65.
As the patient safety field matures, there is increasing recognition of the need to incorporate human factors engineering methods into analyzing errors and developing solutions. These methods were used to investigate the types and frequency of medication errors in two intensive care units. Although existing medication safety interventions have mainly targeted errors at individual stages of the medication management process (e.g., computerized provider order entry [CPOE] to prevent prescribing errors), this study found that in many cases, errors occurred in an interdependent fashion at multiple stages of the process. For example, incorrect transcription of an order could then lead to a medication administration error. While CPOE is likely a solution for a significant proportion of errors, this study's results indicate a need for closed-loop systems that can minimize the risk of all types of medication errors.
Cheung K-C, van der Veen W, Bouvy ML, et al. J Am Med Inform Assoc. 2014;21:e63-70.
Numerous studies have identified unintended consequences associated with health information technology (IT) and computerized provider order entry, but most of these focused exclusively on the hospital setting. This study, which analyzed data from a national database of medication errors in the Netherlands, extends prior studies by examining medication errors related to IT in community pharmacies as well as hospitals. Overall, nearly one in six medication errors was attributable to problems with IT. Human factors engineering issues, such as poorly designed screens and displays, were at the root of a large proportion of these errors. Dr. Donald Norman, a founder of the human factors engineering field, was interviewed by AHRQ WebM&M in 2009.
This study characterizes the types of medication errors documented after introduction of a comprehensive electronic medication management system (that included computerized provider order entry) at two Australian hospitals.
Kullberg A, Larsen J, Sharp L. Eur J Oncol Nurs. 2013;17:228-35.
Cancer patients undergoing chemotherapy may be particularly vulnerable to medical errors, as their care often requires use of high-risk medications and must be closely coordinated between multiple physicians. This thematic review focused on methods to improve safety for chemotherapy patients and found evidence that computerized provider order entry could reduce medication errors. However, the authors did not find enough evidence to recommend other interventions that have been proposed, such as patient engagement or teamwork training for patients and families. An AHRQ WebM&M commentary discusses how one institution responded to a serious chemotherapy error.
Abramson EL, Bates DW, Jenter C, et al. J Am Med Inform Assoc. 2012;19:644-8.
This study, one of the first to analyze prescribing errors in community primary care practices, found a remarkably high rate of errors. Nearly one in four prescriptions contained at least one error in dosing, frequency, or patient instructions, and a startling proportion of prescriptions had illegibility errors as well. Computerized provider order entry (CPOE) could have prevented a large proportion of these errors, and recent studies have shown that CPOE can decrease prescribing errors in community-based office practices. A Patient Safety Primer discusses outpatient medication prescribing errors and other pressing safety issues in outpatient practice.
Abstoss KM, Shaw BE, Owens TA, et al. BMJ Qual Saf. 2011;20:914-22.
This study implemented a series of unit-based safety interventions and discovered notable relationships between improved safety culture and greater medication safety. The authors advocate for interventions that promote a positive safety culture at the unit level.
White CM, Schoettker PJ, Conway PH, et al. BMJ Qual Saf. 2011;20:372-80.
Medication reconciliation is necessary to reduce preventable medication errors, but despite much research, no consensus exists on how the process should be performed in either the inpatient or outpatient setting. This study, conducted at a children's hospital, demonstrates how accurate medication reconciliation can be achieved through establishing a culture of safety and rigorously applying quality improvement principles. Although the hospital had an existing electronic health record and computerized provider order entry system, a reliable medication reconciliation process was not achieved until existing processes were thoroughly analyzed, failure modes were determined, and rapid cycle tests of change were conducted. As medication reconciliation will be reinstated as a National Patient Safety Goal in July 2011, this article provides a useful blueprint for organizations tackling this difficult problem.
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