Non-intercepted dose errors in prescribing anti-neoplastic treatment: a prospective, comparative cohort study.

Area of Science:

• Medical Informatics
• Patient Safety
• Oncology Pharmacy Practice

Background:

• Prescription errors pose a significant risk to patient safety.
• The impact of Computerised Provider Order Entry (CPOE) systems on prescription errors is not well understood.
• Risk factors contributing to non-intercepted prescription dose errors require investigation.

Purpose of the Study:

• To determine the incidence, types, and severity of non-intercepted prescription dose errors.
• To identify risk factors associated with prescription dose errors.
• To compare the error rates between CPOE systems and paper-based prescription forms.

Main Methods:

• A prospective, comparative cohort study was conducted in two oncology units.
• One unit utilized a CPOE system, while the other used paper-based forms.
• Prescription doses were recalculated, with errors defined as a ≥10% difference between administered and recalculated doses.

Main Results:

• A total of 5767 prescriptions were evaluated, with an overall error rate of 1.73 per 100 prescriptions.
• The CPOE system showed a slightly lower error rate (1.60/100) than paper forms (1.84/100), but this difference was not statistically significant (OR=0.87, P=0.49).
• Fifteen error types and four risk factors were identified; no errors led to patient death.

Conclusions:

• Non-intercepted prescribing dose errors occurred in less than 2% of prescriptions.
• The CPOE system did not significantly reduce the overall risk of dose errors and introduced different types of errors.
• Integrated CPOE systems are recommended to improve dose calculations and reduce transcription errors.