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Outpatient CPOE orders discontinued due to ‘erroneous entry’: prospective survey of prescribers’ explanations for errors
  1. Thu-Trang T Hickman1,
  2. Arbor Jessica Lauren Quist1,2,
  3. Alejandra Salazar1,
  4. Mary G Amato1,3,
  5. Adam Wright1,4,5,
  6. Lynn A Volk5,
  7. David W Bates1,4,5,
  8. Gordon Schiff1,4
  1. 1Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
  2. 2Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  3. 3Department of Pharmacy, MCPHS University, Boston, Massachusetts, USA
  4. 4Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
  5. 5Department of Clinical Quality and Analysis, Partners Healthcare System, Somerville, Massachusetts, USA
  1. Correspondence to Thu-Trang T Hickman, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA; thickman{at}bwh.harvard.edu

Abstract

Background Computerised prescriber order entry (CPOE) systems users often discontinue medications because the initial order was erroneous.

Objective To elucidate error types by querying prescribers about their reasons for discontinuing outpatient medication orders that they had self-identified as erroneous.

Methods During a nearly 3 year retrospective data collection period, we identified 57 972 drugs discontinued with the reason ‘Error (erroneous entry).” Because chart reviews revealed limited information about these errors, we prospectively studied consecutive, discontinued erroneous orders by querying prescribers in near-real-time to learn more about the erroneous orders.

Results From January 2014 to April 2014, we prospectively emailed prescribers about outpatient drug orders that they had discontinued due to erroneous initial order entry. Of 2 50 806 medication orders in these 4 months, 1133 (0.45%) of these were discontinued due to error. From these 1133, we emailed 542 unique prescribers to ask about their reason(s) for discontinuing these mediation orders in error. We received 312 responses (58% response rate). We categorised these responses using a previously published taxonomy. The top reasons for these discontinued erroneous orders included: medication ordered for wrong patient (27.8%, n=60); wrong drug ordered (18.5%, n=40); and duplicate order placed (14.4%, n=31). Other common discontinued erroneous orders related to drug dosage and formulation (eg, extended release versus not). Oxycodone (3%) was the most frequent drug discontinued error.

Conclusion Drugs are not infrequently discontinued ‘in error.’ Wrong patient and wrong drug errors constitute the leading types of erroneous prescriptions recognised and discontinued by prescribers. Data regarding erroneous medication entries represent an important source of intelligence about how CPOE systems are functioning and malfunctioning, providing important insights regarding areas for designing CPOE more safely in the future.

  • information technology
  • medication safety
  • patient safety

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Footnotes

  • Contributors TTH and GS: responsible for writing and preparation of manuscript. GS, DWB and AW: responsible for study design. AS and MGA: responsible for review and categorisation of prospective study responses received. TTH, GS, DWB, AW, LAV, AS, MGA and AJLQ: responsible for critical review of the manuscript and data analysis. TTH and AJLQ: responsible for overall management and administrative aspects of this project, as well as management of data.

  • Competing interests None declared.

  • Ethics approval Partners Healthcare IRB.

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

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