RT Journal Article
SR Electronic
T1 Outpatient CPOE orders discontinued due to ‘erroneous entry’: prospective survey of prescribers’ explanations for errors
JF BMJ Quality & Safety
JO BMJ Qual Saf
FD BMJ Publishing Group Ltd
SP 293
OP 298
DO 10.1136/bmjqs-2017-006597
VO 27
IS 4
A1 Thu-Trang T Hickman
A1 Arbor Jessica Lauren Quist
A1 Alejandra Salazar
A1 Mary G Amato
A1 Adam Wright
A1 Lynn A Volk
A1 David W Bates
A1 Gordon Schiff
YR 2018
UL http://qualitysafety.bmj.com/content/27/4/293.abstract
AB 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.