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To the Editor,
We have read with great interest the article by Schiff G D et al.,1
in which 6.1% of errors reported to the United States Pharmacopeia MEDMARX
reporting system were classified as being related to the computerized
prescription order entry (CPOE) system, representing the third most
frequently reported errors in this notification system.
Similarly, in a study conducted in our hospital, appro...
Similarly, in a study conducted in our hospital, approximately 24% of
drug-related problems were due to the use of the CPOE.2 This type of error
was more frequently detected after a team of clinical pharmacists reviewed
the drug treatment of hospital inpatients.
One of the major limitations of current classifications of drug-
related problems is that they do not include the various types of CPOE-
related errors.3,4 Consequently, Schiff et al. developed a new taxonomy
for this type of error, which is essential for epidemiological
surveillance and for the continual improvement of the safety of CPOE
systems. These authors identified the 25 most frequent CPOE-related
errors. Similarly, the 8 most frequent types of CPOE-related error in our
study were the following: 1) Drugs included in the hospital formulary but
prescribed as "not available" in the CPOE (for example, spelling mistakes
or the use of the brand rather than the generic name lead to a failure to
find the drug in the application). 2) Duplicate orders (exact same drug
and dosage). 3) Incorrect entry of a prescribed dose resulting in a higher
or lower recommended dosage. 4) Inappropriate frequency of administration
(frequencies are often specified in a free text comment). For example,
digoxin, 1 tablet per day; the free text comments field may state "except
Saturday and Sunday". Since the free text comment bypasses the computer
circuit designed for discontinuous regimens, the medication chart will
state that this drug should be administered on Saturdays and Sundays. 5)
Inappropriate route of administration. 6) Inappropriate treatment duration
(due to failure to use of the end-date field or days of duration).7)
Unintended discrepancies in dosage (prescribed dosage different from
patients' existing dosage). 8) Designation of a clinical trial drug as
"not included in the hospital formulary" instead of the use of a specific
clinical trials application for the CPOE.
Unlike the study by Schiff et al., one of the most frequently
encountered CPOE-related errors in our experience was prescription of a
drug included in the hospital formulary using an option in the CPOE
designed for those drugs not available in the formulary, which can lead to
a delay in administering the drug to the patient, because the prescribed
drug requires pharmaceutical validation as if it were not included in the
formulary and nursing staff do not visualize it as included in the
medication chart to be administered. Unlike our study, one of the codes
identified by Schiff et al. was nursing administration issues. The lack of
this type of error in our study was due to the specific implantation,
parallel to that of the CPOE, of a computerized application that includes
information on the mode of drug administration for nursing staff with the
aim of unifying this process in the hospital.5 Together with this
information, the application allows the time of administration of each
drug to be specified, such that the time of administration will appear
automatically after its prescription, as well as the compatible diluent(s)
for those drugs requiring dilution.
Our study may have identified a lower number of types of CPOE-related
errors because the sample was drawn from a single hospital and because we
included only those errors due to the use of the CPOE.
In addition to analysing CPOE-related errors, Schiff et al. also
evaluated the causes of these errors and identified codes for their
prevention. Similarly, in our hospital, several strategies were
progressively adopted to reduce this type of error. Thus, administration
units were adapted to paediatric patients, numerous computerized protocols
were designed to standardise drugs associated with specific processes, and
the CPOE was modified to allow visualization, in the lower part of the
admission order, of the drug and dosage previously taken by the patient
before admission. However, several safety aspects related to the CPOE
remain to be resolved.
One of the limitations of our study is that it is difficult to extrapolate
the CPOE system to other hospital settings, given that the system was
designed and developed specifically for the characteristics of our
hospital and is not commercially available. One of the strengths of our
study is that the data are drawn from a prospective review of all the drug
treatments by a team of clinical pharmacists, while data from other
studies have been drawn from voluntary notification systems, which could
lead to underdetection of errors as well as a lack of data on their
In our opinion, the study by Schiff et al. is a highly valuable
contribution, because, in addition to providing a new classification of
CPOE-related errors, it also describes strategies for their prevention.
Given the strong impact of this type of errors, a common classification
system for CPOE-related errors is essential. Such a system would allow
benchmarking between different hospitals independently of the CPOE system
used, which in turn would allow the development of error prevention
systems and/or new CPOE systems to avoid them.
Olatz Urbina Bengoa1, Olivia Ferrandez Quirante1, Marta De Antonio
Cusco1, Nuria Carballo Martinez1
,Santiago Grau Cerrato1
1Pharmacy Department, Hospital del Mar
Pg Maritim, 25-29, CP 08003-Barcelona
1. Schiff GD, Amato MG, Eguale T, et al. Computerised physician order
entry-related medication errors: analysis of reported errors and
vulnerability testing of current systems. BMJ Qual Saf 2015;24(4):264-71.
2. Urbina O, Ferrandez O, Grau S, et al. Design of a score to
identify hospitalized patients at risk of drug-related problems.
Pharmacoepidemiol Drug Saf 2014;23(9):923-32.
3. Pharmaceutical Care Network Europe. The PCNE classification for
drug-related problems V 6.2 [Internet]. 2010; http://www.pcne.org.
(Accesed 22 Nov 2016)
4. van Mil JW, Westerlund LO, Hersberger KE, Schaefer MA. Drug-
related problem classification systems. Ann Pharmacother 2004;38(5):859-
5. Salas E, Bastida M, Grau S, et al. Quality project to improve drug
administration in the hospital trust of thecitycouncil of Barcelona.
International Forum on Quality and Safety in Health Care. British Medical
Journal Group. Barcelona, April 2007. (Oral communication). (Data not