Automatic Errors: A Case Series on the Errors Inherent in Electronic Prescribing.

Area of Science:

• Health Informatics
• Patient Safety
• Clinical Pharmacy

Background:

• Electronic prescribing systems are increasingly adopted to minimize medication errors.
• Handwritten prescriptions are associated with a higher risk of medication errors compared to electronic orders.
• A specific, less-described medication error involves the dispensing of discontinued medications.

Observation:

• Electronic prescribing software transmits new and refill orders but not discontinuation orders to pharmacies.
• Medication discontinuation status is often only visible within the prescribing facility's electronic medical record (EMR).
• Five cases were identified where pharmacies dispensed medications that had been electronically discontinued.

Findings:

• The study identified five instances of pharmacies dispensing electronically discontinued medications.
• Two of these cases resulted in adverse patient outcomes.
• This highlights a critical gap in electronic prescribing workflows regarding medication cessation.

Implications:

• There is a need to improve electronic prescribing systems to include discontinuation notifications to pharmacies.
• Enhanced communication between EMRs and pharmacy systems is crucial to prevent medication errors.
• Addressing this error type can further enhance patient safety and reduce adverse drug events.