Qual Saf Health Care doi:10.1136/qshc.2009.034678
  • Original research

Medication prescribing and monitoring errors in primary care: a report from the Practice Partner Research Network

  1. S M Ornstein
  1. Medical University of South Carolina, Charleston, South Carolina, USA
  1. Correspondence to Andrea M Wessell, Department of Family Medicine, Medical University of South Carolina, 295 Calhoun Street, Charleston, SC 29425, USA; Wessell{at}
  • Accepted 14 November 2009
  • Published Online First 22 April 2010


Introduction Medication errors have been associated with poor patient outcomes and pose significant public health consequences. Establishing medication safety quality indicators is crucial to capturing the pervasiveness of preventable errors and is a fundamental first step in the process of improvement. In this article, a study is presented in which a set of medication prescribing and monitoring quality indicators were developed, and adherence to them was assessed among a group of US primary care practices.

Methods Twenty Practice Partner Research Network practices in 14 US states with 94 clinicians and 52 246 active adult patients participated in the study. All practices use a common electronic medical record with dosing, interaction and monitoring decision support features. A consensus development process was used to select indicators in the categories of inappropriate treatment, dosing, drug–drug and drug–disease interactions, and monitoring of potential adverse events. Data extracted electronically from practices' electronic medical record were used to assess practice-level adherence with the indicator set as of 1 July 2008.

Results Thirty medication safety indicators were selected. Across all practices, inappropriate treatment, dosing, drug–drug and drug–disease interactions were avoided in 75%, 84%, 98% and 86% of eligible patients, respectively; monitoring of preventable adverse drug events occurred in 75% of patients. There was wide variability in practice adherence with the indicators.

Discussion The consensus development process was successful in selecting a broad set of primary care medication safety quality indicators. Although aggregate adherence was relatively high in this group of practices, opportunities exist to improve potential errors in treatment selection, dosing and monitoring.


  • Funding This study was funded by the Agency for Healthcare Research and Quality Ambulatory Safety and Quality Program, Improving Quality through Clinician Use of Health Information Technology Grant No. 1R18HS017037-01. The funding agency had no role in the study design; in collection, analysis and interpretation of data; in writing of the report; and in the decision to submit the paper for publication.

  • Competing interests AMW and SMO are consultants for McKesson Practice Partner, the vendor of the electronic medical record used by practices in this study.

  • Ethics approval This study was conducted with the approval of the Institutional Review Board for Human Research at the Medical University of South Carolina.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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