Examining medication ordering errors using AHRQ network of patient safety databases.

Area of Science:

• Health Informatics
• Patient Safety
• Medication Error Analysis

Background:

• Computerized provider order entry (CPOE) was intended to reduce medication ordering errors but has not consistently achieved this goal.
• Existing studies show mixed results regarding CPOE's effectiveness in preventing medication errors.
• This study investigates the types and harm levels of medication ordering errors reported through a national patient safety database.

Purpose of the Study:

• To analyze the frequency and degree of harm of medication ordering errors reported to the Agency for Healthcare Research and Quality (AHRQ) Network of Patient Safety Databases (NPSD).
• To characterize medication ordering errors by error type and severity.
• To identify the most common and harmful medication ordering errors to inform future intervention development.

Main Methods:

• Retrospective observational study utilizing data from the AHRQ NPSD from June 2010 to December 2020.
• Analysis of all reported medication and other substance ordering errors submitted via common format v1.2.
• Categorization of errors by type, degree of harm, and demographic characteristics.

Main Results:

• A total of 12,830 medication ordering errors were reported during the study period.
• Incorrect dose (29.7%) and incorrect medication (16.3%) were the most frequent error types.
• Of events reaching patients, 12 resulted in death, 4 in severe harm, 45 in moderate harm, and 341 in mild harm.

Conclusions:

• Incorrect dose and incorrect drug errors are the most common and harmful types of medication ordering errors.
• Despite CPOE implementation, significant medication ordering errors persist.
• Future research should focus on developing and testing CPOE-specific interventions targeting wrong-dose and wrong-drug errors.