Electronic prescription: frequency and severity of medication errors

Area of Science:

• Health Informatics
• Patient Safety
• Clinical Pharmacy

Background:

• Medication errors pose a significant risk to patient safety.
• Computerized Provider Order Entry (CPOE) systems are implemented to reduce prescription errors.
• The impact of CPOE on error rates can vary depending on the implementation and hospital context.

Purpose of the Study:

• To evaluate the frequency and severity of prescription errors involving high-alert medications (heparin and potassium chloride) before and after CPOE implementation.
• To compare the effects of CPOE on prescription errors in two distinct high-complexity hospitals.

Main Methods:

• A retrospective study comparing manual/pre-typed prescriptions (2007) with CPOE prescriptions (2014).
• Analysis of 1,028 prescriptions from two high-complexity hospitals in Belo Horizonte, Brazil.
• Assessment of both error frequency and severity for heparin and potassium chloride.

Main Results:

• Hospital 1 experienced a 25% increase in prescription error frequency post-CPOE (p<0.001), with no change in potassium chloride error rates.
• Hospital 2 observed an 85% decrease in error frequency post-CPOE (p<0.001), including a significant reduction in potassium chloride errors.
• Error severity decreased for heparin (p<0.001) but remained unchanged for potassium chloride (p>0.05).

Conclusions:

• CPOE implementation had differential effects on prescription error frequency and severity across the two hospitals.
• Thorough monitoring is crucial during and after CPOE system modifications to identify and mitigate new potential errors.
• Proactive measures are necessary to prevent medication errors associated with the adoption of new prescription technologies.