Ordering systems in hospitals increase medication errors
Computerised systems for ordering medicines in a hospital setting can increase the risk of adverse drug events, says new research from the US.
Although computerised physician order entry (CPOE) systems have previously
been shown to reduce medication errors, authors of a new study have identified
22 types of medication error risks facilitated by the electronic ordering
system TDS in a large American teaching hospital.
The researchers shadowed hospital doctors ordering medicines and pharmacists
reviewing the orders. They interviewed pharmacists, house doctors, nurses
and IT managers about the error risks they had observed.
Medication error risks identified included pharmacy stock lists being
mistaken for dosage guidelines, fragmented displays preventing a complete
patient medication record from being revealed and inflexible ordering
formats leading to incorrect orders being generated. In some cases, the
system allowed doctors to order diluents that were incompatible with
antibiotics they were prescribing or warned about medicine allergies
only after the product had been ordered. In these cases, house doctors
were often relying on pharmacists to perform checks.
Three quarters of the staff interviewed reported having observed each
of these potential causes of medication errors which the authors say
indicates that they occur weekly or more often (JAMA 2005;293:1197).
The author of an accompanying editorial says: “Since roughly 75
per cent of all large IT projects in health care fail, inattention to
these lessons is, at best, wasteful of time and resources and, at worst,
harmful to patients and clinicians (ibid, p1261).” |
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Pharmaceutical Journal
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