Risk factors associated with medication ordering errors.

Area of Science:

• Healthcare Informatics
• Patient Safety
• Medication Error Analysis

Background:

• Medication ordering errors are a significant concern in patient safety.
• Identifying and analyzing these errors is crucial for developing effective interventions.

Purpose of the Study:

• To characterize medication ordering errors using a "void" function in a computerized order entry system.
• To investigate risk factors contributing to these errors.
• To explore strategies for mitigating identified risk factors.

Main Methods:

• Utilized a "void" function within a computerized order entry system to capture erroneous medication orders.
• Collected data through clinician interviews, surveys, and chart reviews.
• Applied the Systems Engineering Initiative for Patient Safety (SEIPS) model to analyze work system-based risk factors.

Main Results:

• Over 16 months, 1074 orders were voided, with 842 identified as true medication errors (78.3% accuracy).
• 22% of errors reached patients without causing harm.
• Errors stemmed from multifactorial contributors across technological, cognitive, environmental, social, and organizational levels.

Conclusions:

• The "void" function provides a practical method for creating a database of medication ordering errors.
• Findings have implications for future research, clinical practice, and learning opportunities in medication safety.