Indication alerts intercept drug name confusion errors during computerized entry of medication orders

Area of Science:

• Health Informatics
• Patient Safety
• Clinical Decision Support

Background:

• Medication errors due to similar drug names are a significant patient safety concern.
• Current interventions at the prescribing stage have shown limited success in preventing these errors.

Purpose of the Study:

• To evaluate the effectiveness of indication alerts within computerized physician order entry (CPOE) systems in intercepting drug name confusion errors.

Main Methods:

• A retrospective observational study analyzed data from a tertiary hospital and ambulatory practice using CPOE.
• Indication alerts were triggered when medications were ordered without a coded indication in the electronic problem list.
• Error interception was defined by an alert, order cancellation, and subsequent ordering of a similar drug by the same prescriber within 5 minutes.

Main Results:

• The study included 54,499 unique patients and analyzed 127,458 alerts.
• A total of 176 drug name confusion errors were intercepted, resulting in an interception rate of 0.14% ± 0.01%.
• This equates to 1.4 intercepted errors per 1000 alerts.

Conclusions:

• Indication alerts are a viable strategy for intercepting drug name confusion errors within CPOE systems.
• Healthcare institutions utilizing CPOE should consider implementing indication prompts to enhance medication safety.