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[Inability of hospital computerised physician order entry systems to secure the use of concentrated potassium

Pauline Klein1, Jeremy Bonhomme2, Cindy Bourne3

  • 1Service pharmaceutique, hôpital de la Croix-Rousse, groupement hospitalier Nord, hospices civils de Lyon, 103, grande rue de la Croix Rousse, 69317 Lyon cedex 04, France.

Annales Pharmaceutiques Francaises
|October 25, 2023
PubMed

Insights

Hospital computerised physician order entry (CPOE) systems do not adequately secure intravenous potassium chloride (KCl) prescriptions. Many CPOE systems allow unsafe high-risk medication orders, posing a significant patient safety risk.

Area of Science:

  • Pharmacovigilance
  • Health Informatics
  • Medication Safety

Context:

  • Intravenous potassium chloride (KCl) is a high-alert medication requiring careful prescription and administration.
  • French healthcare agencies have issued recommendations for securing KCl prescriptions.
  • Hospital computerised physician order entry (CPOE) systems are widely implemented for medication ordering.

Purpose:

  • To evaluate the capability of hospital CPOE systems in securing intravenous KCl prescriptions.
  • To assess compliance of CPOE systems with French healthcare agency recommendations for KCl.
  • To identify vulnerabilities in CPOE systems regarding high-risk medication prescribing.

Summary:

  • A survey of 23 CPOE systems revealed significant limitations in securing intravenous KCl prescriptions.
  • Many CPOE systems allow unsafe prescribing practices, including incorrect dilutions, concentrations, and administration routes.
  • Over 75% of CPOE systems permit prescribing concentrated KCl without dilution and high concentrations (up to 6g/L).

Impact:

  • Current CPOE systems are insufficient for ensuring the safe prescription of injectable KCl.
  • This highlights a critical gap in health information technology's role in medication safety.
  • Mandatory improvements in CPOE systems are needed, focusing on dilution, concentration, and infusion rate controls for high-risk drugs like KCl.
Abstract

Keywords:
Chlorure de potassiumComputerised physician order entry systemErreur médicamenteuseIntravenous routeLogiciel de prescriptionMedication errorPotassium chlorideVoie intraveineuse

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