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Medication errors related to computerized order entry for children.

Kathleen E Walsh1, William G Adams, Howard Bauchner

  • 1Department of Pediatrics, University of Massachusetts Medical School/University of Massachusetts Memorial Medical Center, 55 North Lake St, Worcester, MA 01655, USA. walshk02@ummhc.org

Pediatrics
|November 3, 2006
PubMed
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Computerized order entry systems can cause new pediatric medication errors. Serious computer-related errors are uncommon, but system design flaws contribute to medication mistakes in children.

Area of Science:

  • Pediatric Patient Safety
  • Health Informatics
  • Medication Error Analysis

Background:

  • Computerized order entry (COE) systems aim to improve medication safety.
  • However, system design can inadvertently introduce new types of errors.

Purpose of the Study:

  • To determine the frequency and types of pediatric medication errors linked to COE system design.
  • To analyze the impact of COE on pediatric medication safety.

Main Methods:

  • Retrospective review of 352 pediatric admissions (1930 patient-days).
  • Identification and classification of medication errors using active surveillance.
  • Categorization of computer-related errors by type.

Main Results:

Related Experiment Videos

  • 104 pediatric medication errors identified, 71 serious.
  • 19% of errors (10 per 1000 patient-days) were computer-related.
  • Identified error types: duplicate orders, drop-down errors, keypad entry, and order set issues.

    • Conclusions:

    • Serious pediatric computer-related errors are infrequent (3.6 per 1000 patient-days).
    • COE systems can introduce novel pediatric medication errors not seen in paper systems.
    • System design improvements are crucial for enhancing pediatric medication safety.