Implementation of a custom alert to prevent medication-timing errors associated with computerized prescriber order...

Area of Science:

• Health Informatics
• Patient Safety
• Clinical Systems

Background:

• Computerized prescriber order-entry (CPOE) systems can lead to medication-timing errors.
• Preventing these errors is crucial for patient safety and effective medication management.

Purpose of the Study:

• To describe the implementation of a custom alert designed to prevent medication-timing errors.
• To evaluate the effectiveness of this alert in a CPOE system.

Main Methods:

• A custom 'self-inspect with pause' alert was developed for the CPOE system.
• The alert targeted medications administered once or twice daily.
• An interrupted time series analysis compared medication-timing errors before and after alert implementation.

Main Results:

• The proportion of prescribers modifying orders due to the alert increased significantly from 12% to 29%.
• This modification rate continued to rise five months post-implementation.
• Medication-timing errors reaching patients decreased by 50% after the alert was introduced.

Conclusions:

• A customized alert effectively corrected medication-timing errors within a CPOE system.
• The intervention demonstrated a significant positive impact on patient safety by reducing medication errors.