Medication Errors, Patient Safety & Computer Prescriber Order Entry (CPOE) | Steve Leuck, PharmD | RxEconsult

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Review of Medication Errors, Patient Safety and Computer Prescriber Order Entry (CPOE) Category: Healthcare Practice by - March 22, 2014 | Views: 33668 | Likes: 3 | Comment: 2  

Medication Error

If asked for the meaning of “patient safety” how would you answer? Perhaps you would remember hearing somewhere about a patient who went to the hospital for a knee replacement surgery, and when they woke from anesthesia in the recovery room they found that they in fact did have a brand new knee; however, it was done on the wrong leg. Or, maybe you would think back to your elderly relative who left the hospital bed to use the restroom, slipped on the floor and fractured a hip.   

The Department of Health and Human Services wrote a paper in 2010 based upon data collected regarding hospital related adverse events (preventable or not) in 2008. The findings showed that in 2008, more than 13.5% of all Medicare beneficiaries admitted to hospitals had some sort of hospital related adverse event. Of these, fewer than 50% were considered "clearly or likely preventable".  It was estimated that 1.5% of this population (with a projection of 180,000 people per year) experienced and adverse event that contributed to their death. 

The Journal of Patient Safety published an article in September 2013 which took a fresh look at the incidence of patient deaths related to medical errors in hospitals. Until this review, the most recent relevant data on the subject was nearly 3 decades old. The current article determined, through retrospective literature review, that preventable medical adverse events account for at least 210,000 deaths per year, and more likely the number is closer to 400,000 deaths per year. 

According to the Center for Disease Control, if these numbers are correct, preventable adverse events due to medical errors should be listed as the third leading cause of death in the United States, behind heart disease and cancer. 

When discussing patient safety in the health care environment, such as in a hospital or nursing home, concerns such as hospital acquired infections, patient falls, surgical complications as well as a host of other items round out the list of top 10 patient related safety issues. Included in this list are medication errors.  

Based on a study published in the Annals of Intensive Care in Feb. 2012, medication errors are the most common form of medical error; however, an exact percentage is difficult to identify. 

Medication errors may happen at any point along the continuum of hospital care including:

  • Prescriber writing or entering medication order
  • Pharmacy review of medication order
  • Preparation of medication for delivery
  • Delivery of medication order to ward
  • Access of medication by nursing staff
  • Delivery of medication to patient
  • Monitoring of patient

Based upon a recent review article, the three most common types of medication related errors include:

  • Not giving the medication (medication omission)
  • Giving the wrong dose of medication
  • Prescribing error

This process of reporting and identifying the types and causes of medication related errors and adverse events has significantly advanced understanding of how to prevent these types of errors. For quite some time now, the discussion of Computer Prescriber Order Entry (CPOE) has been the focus of many hospital agencies, with a focus on how a completely computerized order entry process may potentially and significantly decrease medication related adverse events. 

In 2012, the Journal of American Medical Information Association performed a retrospective review of hospitals that had implemented CPOE systems and compared that to the percentage of medication related adverse events reported. The results of this study show that there is an astounding 48% decrease in medication error when a hospital processes the order through a CPOE system. 

With these numbers, it would seem that more hospitals would be rushing to implement CPOE systems; however, a 2013 article states that as of 2011 only 20-25% of the hospitals in the United States have adopted such systems. With federal mandates from both Stage 1 and Stage 2 meaningful use standards, we should see a steep rise in the adoption rates of CPOE systems by hospitals in order for the facilities to maintain their Medicare accreditation. 

Personally, I have experience working in two different hospitals that have adopted CPOE order systems. Although both systems are different, they are remarkably similar in the amount of knowledge available in a single screen. The ability to check and cross check doses, allergies, therapeutic duplications, laboratory results, previous hospital visits, reconciliation of home medications and coordinating prescriber responsibility is priceless. Yes, there is a steep learning curve for those who are not incredibly familiar with computers and medication errors can still occur. However, with proper training, a responsive service hotline and a positive attitude, it is well worth the cost  if leads to a decrease in preventable adverse medication events.

About the Author

Steve Leuck, Pharm.D., is President/Owner of AudibleRx. Dr. Leuck also works full time as a Community Pharmacist in a clinic setting where he practices his counseling on a daily basis. 


Adverse events in hospitals: National incidence among medicare beneficiaries

A new evidence based estimate of patient harms associated with hospital care.

Medical errors may be the country's third leading cause of death.

Top ten patient safety issues for 2014

Overview of medical errors and adverse events.

Medication mistakes: Types and causes.

Reduction in medication errors in hospitals due to adoption of computerized provider entry systems.

CMIO: Some hospitals have no plan for CPOE implementation


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