Learning from errors: analysis of medication order voiding in CPOE systems.

Area of Science:

• Health Informatics
• Patient Safety
• Clinical Pharmacy

Background:

• Medication ordering errors pose a significant risk to patient safety.
• Electronic health record (EHR) systems offer functionalities that may aid in error identification.
• The medication order voiding function is a feature within EHRs designed to correct erroneous orders.

Purpose of the Study:

• To determine if the medication order voiding function can be utilized to record and analyze medication ordering errors.
• To assess the prevalence of medication ordering errors among voided orders.
• To evaluate the accuracy of clinician-provided reasons for voiding orders.

Main Methods:

• Analysis of over 5.8 million medication orders from an academic medical center (2006-2011).
• Categorization of orders by void status and clinician-reported voiding reasons.
• Multivariable logistic regression to identify factors associated with order voiding.
• Chart review of 198 voided orders to confirm error rates and reason accuracy.

Main Results:

• 0.49% of all medication orders were voided.
• Order voiding was associated with clinician type and order type.
• An estimated 70% ± 10% of voided orders were attributed to medication ordering errors.
• Clinician reasons for voiding were accurate for duplicate orders (72%) but less so for other error types.

Conclusions:

• The order voiding function in EHRs presents a feasible, low-effort method for self-reporting medication ordering errors.
• Utilizing voided orders can contribute valuable data for medication safety initiatives, learning, and training.
• Enhanced clinician training on using the voiding function can improve the quality and utility of reported error data.