Reducing prescribing errors: making electronic prescribing work for cystic fibrosis inpatients

Area of Science:

• Pediatric Medicine
• Clinical Pharmacy
• Health Informatics

Background:

• Pediatric patients with cystic fibrosis often experience medication errors.
• Polypharmacy and the use of specialist/high-risk medications contribute to these errors.
• Existing electronic prescribing systems may not fully prevent errors.

Purpose of the Study:

• To describe a multidisciplinary quality improvement project to reduce medication errors in pediatric cystic fibrosis patients.
• To evaluate the impact of combining a computerized order entry system (CPOE) with human factor process changes.

Main Methods:

• A multidisciplinary team implemented a quality improvement project.
• The project integrated a CPOE system with human factor process modifications.
• Data was collected and analyzed over a 12-month period using run charts.

Main Results:

• A 43% reduction in overall prescription errors was observed.
• For medications managed by the CPOE, errors reaching the patient decreased from 50% to 29%.
• The study highlights the need for adaptable electronic systems and team engagement.

Conclusions:

• Combining CPOE with human factor changes is effective in reducing medication errors in pediatric cystic fibrosis care.
• Electronic prescribing systems require adaptation and clinician engagement to maximize safety benefits.
• Multidisciplinary collaboration and attention to human factors are crucial for improving medication safety.