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Chua K-P, Brummett CM, Conti RM, et al. Pediatrics. 2021;148:e2021051539.
Despite public policies and guidelines to reduce opioid prescribing, providers continue to overprescribe these medications to children, adolescents, and young adults. In this analysis of US retail pharmacy data, 3.5% of US children and young adults were dispensed at least one opioid prescription; nearly half of those included at least one factor indicating they were high risk. Consistent with prior research, dentists and surgeons were the most frequent prescribers, writing 61% of all opiate prescriptions.
Cerqueira O, Gill M, Swar B, et al. BMJ Qual Saf. 2021;30:1038-1046.
Computerized prescriber order entry (CPOE) systems embedded in electronic health systems alert clinicians to potential safety concerns such as drug-drug interactions or medication dosage errors. Results of this review indicate that alerts influenced prescriber behavior in most of the included studies. However, it is unclear whether these behavioral changes improve patient safety outcomes. Recommendations for future research include randomized controlled trials to determine which alerts maximize patient safety, while minimizing prescribers’ alert fatigue.
Srinivasamurthy SK, Ashokkumar R, Kodidela S, et al. Eur J Clin Pharmacol. 2021;77:1123-1131.
Computerized prescriber (or physician) order entry (CPOE) systems are widely used in healthcare and studies have shown a reduction in medication errors with CPOE. This study focused on whether CPOE systems improved the incidence of chemotherapy-related medication errors. The study included 11 studies in the review but only 8 studies were in the meta-analysis. The authors found that the use of CPOE was associated with an 81% reduction in chemotherapy-related medication errors, indicating that CPOE is a valuable strategy for this patient population.
Co Z, Holmgren AJ, Classen DC, et al. Appl Clin Inform. 2021;12:153-163.
Medication errors occur frequently in ambulatory care settings. This article describes the development and testing of an ambulatory medication safety evaluation tool, which is based on an inpatient version administered by The Leapfrog Group. Pilot testing at seven clinics around the US indicates that clinics struggled in areas of advanced decision support such as drug age and drug monitoring, and that most clinics lacked EHR-based medication reconciliation functions.
Delvaux N, Piessens V, Burghgraeve TD, et al. Implement Sci. 2020;15:100.
Clinical decision support systems (CDSS) and computerized physician order entry (CPOE) have the potential to improve patient safety. This randomized trial evaluated the impact of integrating CDSS into CPOE among general practitioners in Belgium. The intervention improved appropriateness and decreased volume of laboratory test ordering and did not show any increases in diagnostic errors.
Powell L, Sittig DF, Chrouser K, et al. JAMA Netw Open. 2020;3:e206752-e.
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.
Salazar A; Karmiy SJ; Forsythe KJ; Amato MG; Wright A; Lai KH; Lambert BL; Liebovitz DM; Eguale T; Volk LA; Schiff GD.
Medication errors occur frequently in the outpatient setting and can lead to patient harm. A common scenario is one in which a patient is prescribed multiple medications, does not know what each one is for, and takes them incorrectly. Medication safety experts have advocated that prescribers include indications on prescription labels to enable patients and pharmacists to check the bottle in order to remember a medication's purpose. Investigators examined more than 4 million outpatient prescriptions from a single institution and found that only 7.4% of prescriptions included an indication. Medications for symptoms like pain, nausea, and anxiety were much more likely to have indications than medications for chronic diseases. Internal medicine physicians, whose patients are more likely to take multiple medications, wrote indications 6% of the time. A PSNet perspective explored how community pharmacists can use medication indications and other tools to ameliorate medication-related harm.
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, Kashyap N, et al. J Am Med Info Asso. 2018;25:1516-1523.
Many ambulatory electronic health records cannot communicate to pharmacies that medications should be discontinued. In a nationally representative sample, nearly 1% of new prescriptions had discontinuation instructions for other prescriptions embedded within them, a workaround that creates inefficiencies and new safety hazards. A recent interview with Michael Cohen, President of the Institute for Safe Medication Practices, discussed this and other safety concerns that community pharmacies face.
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.
Ai A, Wong A, Amato MG, et al. J Am Med Inform Assoc. 2018;25:709-714.
Electronic prescribing is a pillar of patient safety, but computerized provider order entry may also introduce errors. This study examined the extent to which prescribers erroneously entered free text into electronic medication orders to communicate to pharmacists about medication. More than 10% of medication orders exhibited a communication failure between prescriber and pharmacist. Investigators also found that 38% of these communication failures conferred a risk for significant or severe harm to patients. This study demonstrates the need to facilitate communication between prescribers and pharmacists within the electronic ordering process to prevent adverse medication events. A past WebM&M commentary discussed strategies to reduce errors associated with electronic prescribing.
Battis B, Clifford L, Huq M, et al. J Oncol Pract. 2017;23:582-590.
Oral chemotherapy regimens are complex and may lead to severe adverse drug events. In this pilot study, nearly half of patients enrolled in a pharmacist-run oral chemotherapy monitoring clinic experienced a medication-related problem. This finding is consistent with prior studies that demonstrated pharmacist oversight improves safety of oral chemotherapy.
Overhage JM, Gandhi TK, Hope C, et al. J Patient Saf. 2016;12:69-74.
Adverse drug events (ADEs) are a common source of patient harm in the ambulatory setting. A substantial proportion of ADEs are caused by preventable errors in medication prescribing or monitoring. The introduction of computerized provider order entry (CPOE) has been shown to reduce the rate of medical errors in the inpatient setting. This before–after study examined rates of ADEs in primary care practices that implemented a CPOE system in Boston and Indianapolis. At baseline, the potential ADE rate was more than seven-fold greater in Indianapolis compared to Boston. Following CPOE implementation, this rate decreased by 56% in Indianapolis but increased by 104% in Boston, and there was no change overall in preventable ADEs. A recent PSNet annual perspective reviewed the relationship and current evidence linking CPOE and patient safety.
Slight SP, Beeler PE, Seger DL, et al. BMJ Qual Saf. 2016;26.
Clinical decision support systems are intended to improve safety by providing clinicians with information about potential harms—principally harmful drug interactions and allergies—at the point of care. Analyzing more than 150,000 drug allergy warnings in the inpatient and outpatient settings within a single health care system, this study examined how often the warnings were overridden and the appropriateness of prescribers' reasons for doing so. Clinicians overrode 81% of warnings in hospitalized patients and 77% of alerts in outpatients. More than 96% of the overrides were judged appropriate by independent clinical reviewers. These proportions are similar to prior studies. A common appropriate reason for overriding was that the patient had actually tolerated the drug in question, leading the authors to call for improving the accuracy of allergy documentation in electronic medical records. A few classes of drugs accounted for a large proportion of overridden alerts, suggesting that enhancing the accuracy of allergy warnings for these drugs could significantly reduce the overall burden of alerts. Given that alert fatigue is an increasingly recognized patient safety hazard, creating tailored alerts could help clinical decision support systems achieve their potential to improve safety.
Hsu C-C, Chou C-Y, Chou C-L, et al. PLoS One. 2014;9:e114359.
Clinicians may prescribe split pills for many different reasons, including dosing flexibility and patient affordability; however, this practice presents potential hazards. Splitting medications that are formulated to be extended-release or enteric-coated can lead to possibly dangerous changes in the drug's functionality. This study discusses the introduction of a clinical decision support warning that created a "hard stop" for any time an outpatient clinician attempted to prescribe a split pill for these special formulation medications. The study site was an academic medical center in Taiwan that performs more than 2.5 million ambulatory visits per year. The intervention resulted in a sharp decline in inappropriate medication splitting from a rate of approximately 0.61% to below 0.2%, where it has remained for at least 10 consecutive months. The use of a hard stop order can be controversial, as this method has resulted in unintended consequences in the past. A prior AHRQ WebM&M perspective discussed some of the tensions related to implementing medication decision support systems.
Odukoya OK, Stone JA, Chui MA. Res Social Adm Pharm. 2014;10:837-852.
The handwritten prescription pad is vanishing from clinical practice, replaced by the proliferation of e-prescribing. There are many advantages to this technology, but prescribing errors still occur at alarming rates. This study explored the approaches community pharmacists and technicians utilize to detect and manage e-prescription errors.
Kukreti V, Cosby R, Cheung A, et al. Curr Oncol. 2014;21:e604-12.
Medication error rates are extremely high among patients receiving outpatient chemotherapy. This systematic review found a paucity of studies on the effectiveness of computerized provider order entry (CPOE) in improving the safety of chemotherapy, but concluded that the limited evidence supports wider use of CPOE in this setting.
Galanter WL, Bryson ML, Falck S, et al. PLoS One. 2014;9:e101977.
Clinicians use thousands of prescription medications during routine care, and new medications are regularly incorporated into practice. Confusion between medications with names that appear or sound similar is a common cause of medication errors. This observational study sought to determine whether a computerized provider order entry system—with an alert that prompted providers to enter the indication when certain medications were ordered and required users to click "OK" to ignore the alert, to add the drug to a problem list, or to cancel the order—identified drug name confusion errors. These alerts intercepted 1.4 drug name confusion errors per 1000 alerts. While authors recommend that these alerts be implemented to decrease medication errors, they suggest narrowing the number of medications selected to prompt alerts to reduce risk of alert fatigue. A previous AHRQ WebM&M commentary describes an incident involving a look-alike drug error and reviews strategies to enhance safety of medication selection.
Forrester SH, Hepp Z, Roth JA, et al. Value in Health. 2014;17.
Most research on computerized provider order entry (CPOE) has focused on its role in preventing medication errors. This modeling study sought to determine the cost-effectiveness of CPOE in the ambulatory setting. The authors used prior data on changes in adverse drug event rates both before and after implementation of electronic prescribing to estimate the benefit of CPOE for outpatient medication safety. Exploring four simulations varying in practice sizes and characteristics, they found that CPOE was cost-effective and associated with fewer medication errors. These data support further implementation of electronic prescribing, despite concerns about introducing new errors with health information technology. A previous AHRQ WebM&M perspective discusses how to design safer CPOE systems.