New Tool to Reduce Errors

The researchers used a hospital’s computerised physician order entry (CPOE) system to track prescriptions that were discontinued within 45 minutes. They found the rate of errors among the quickly stopped orders was 66 percent.

The team interviewed the prescribing physicians, asking about why they stopped the orders - looking at both who caught the error and the doctor’s own explanation for the change. Often the reason for the change was obvious, for example a medication for the wrong eye, or a dose far too large. Sometimes the reasons were more subtle, like a more appropriate antibiotic.

The classes of drugs most likely to be quickly discontinued made sense to the scientists because they were often among the most difficult-to-prescribe: low therapeutic index drugs, insulin, antiretrovirals, antineoplastics, and immunosuppressive drugs.

The researchers had a live transmission of every medication order as it was written, and were able to interview the ordering physicians within hours or even minutes. The team conducted the research over the course of two months, selecting times and days that reflected the physicians’ ordering patterns at the hospital.

Even beyond the ratio comparisons, the value of this measure is several-fold: When linked to a CPOE system, it is rapid, constant, and does not depend on possibly biased evaluators, self-report, or others’ reports. Data collection is also cost-free as part of a CPOE system.

Difficulties identifying and measuring medication errors are a constant theme of the hospital patient safety literature, according to the scientists. They see their new method not as replacing the others, but as additional technique that appears both efficient and objective. It could identify and help physicians who are having problems with a particular group of medications or patient types and could help post-graduate medical educators focus on areas requiring additional training.

MEDICA.de; Source: University of Pennsylvania School of Medicine