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E-Prescribing Does Not Prevent Errors

Outpatient electronic prescribing systems don’t cut out the common mistakes made in manual systems, suggests published research in JAMIA.

More than 10% of electronic prescriptions contain an error, according to a new study that determined that prescriptions sent electronically are just as likely to contain mistakes as handwritten ones.

E-prescribing has been heralded by health reform experts and policymakers as a way to reduce medication errors, and the federal government is devoting billions to foster it.

Although most evidence suggests enthusiasm for a more paperless medical system is well-founded, new technology can also introduce new potential for medication errors, Karen Nanji, MD, of Massachusetts General Hospital in Boston, wrote in a paper published in the Journal of American Medical Information Association.

The researchers analyzed 3,850 computer-generated prescriptions received by a commercial pharmacy chain in three states over four weeks in 2008. All of the prescriptions originated from outpatient computerized prescribing systems used in physician offices by providers caring for patients outside the hospital. A clinical panel reviewed the prescriptions for medical errors and examined whether those errors had the potential to harm the patient.

Mistakes were classified as: significant but posing little serious threat to life, such as rash, headache, or diarrhea; serious but not life threatening, such as low blood sugar (hypoglycemia), reduced heart rate (bradycardia), and fainting (syncope); and life threatening if not treated, such as heart attack and respiratory failure.

In total, 11.7% of the prescriptions contained some sort of error, and 4% of the total prescriptions contained errors that were serious enough to potentially cause an adverse event (most of which were classified as “significant” or “serious” events, although none were life-threatening).

That’s about the same rate of errors that previous studies have found are present in handwritten prescriptions, according to the authors.

“Implementing a computerized prescribing system without comprehensive functionality and processes in place to ensure meaningful use of the system does not decrease medication errors,” they wrote.

Errors were most common in prescriptions for anti-infectives, which accounted for 17.3% of the mistakes. The next most common were nervous system drugs, followed by respiratory drugs.

Four out of 10 medication errors involved anti-inflammatory drugs and antibiotics (anti-infectives), and the most common types of drugs associated with errors were nervous system drugs (27%), cardiovascular drugs (13.5%), and anti-inflammatories/antibiotics (12.3%).

About two-thirds of the errors were omissions. For instance, some of the prescriptions left the duration, dose, or frequency blank.

Omitted dose was the most likely mistake to be classified as a having the potential to cause adverse events. Other errors included confusing information, such as telling a patient to take the drug “as directed,” but not elaborating any further.

In some cases, the errors would have resulted in overdoses if a patient followed the dosing instructions on the prescription. In one case, for instance, a patient was directed to take five 500 mg Vicodin tablets every four to six hours.

The prevalence of prescribing errors varied considerably, depending on the system used, ranging from 5% to 37% among the 13 systems analyzed. The frequency of certain types of errors was also associated with particular systems.

For example, in system A, omitting to specify length of treatment and dose were common, and “miscellaneous” errors accounted for more than one in four mistakes (27%). And while system B’s error rate was less than that of system G, system B incurred substantially more potentially harmful errors.

Around 60% of errors related to missing information, which the authors suggest should be relatively easy to eliminate by some judicious tweaking or providing better training for the users.¬†Some errors as writing the wrong patient name or wrong diagnosis is an error that e-prescribing systems can’t fix.

Options might include “forcing functions” which would not allow a prescription to be completed if certain information were missing; decision support systems, such as maximum dose checks; and calculators, they say.

“These data are especially important now because providers are currently rapidly adopting electronic health records, yet may not realize the full range of benefits if the prescribing applications have some of the issues we identified,” the authors wrote.

They outlined a number of ways to reduce errors in e-prescribing, including programming the computerized system so that it does not allow information to be omitted, incomplete drug names, and inappropriate abbreviations.

The authors also recommended systems that have built-in calculators that can figure dosing so the prescriber doesn’t have to do the math.

The authors acknowledged limitations of their study, including the fact that they weren’t able to tell whether a prescription was a “true electronic prescription,” that is, whether it was transmitted from a computer in the physician’s office to the pharmacy’s computer, or whether it was just printed out from a computer and physically brought to the pharmacy.

Nanji KC, et al “Errors associated with outpatient computerized prescribing systems” J Am Med Inform Assoc 2011; DOI:10.1136/amiajnl-2011-000205.