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• Authors response: Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors
  Olivia Ferrandez Quirante
  Published on: 8 December 2016

• Published on: 8 December 2016

  Authors response: Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors

  • Olivia Ferrandez Quirante, Pharmacist, PhD, BCPS
  • Other Contributors:
    • Olatz Urbina Bengoa, Marta De Antonio Cusco, Nuria Carballo Martinez, Santiago Grau Cerrato

  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...

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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, 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 registration.

  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 Tel: 932483704 Fax: 932483256

  References

  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- 67.

  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 published).

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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