Despite the perception that technology is the panacea that will improve patient safety and reduce medication errors, nearly 20 percent of hospital and health system medication errors reported to USP’s MEDMARXSM program in 2003 involved computerization or automation. However, facilities that have implemented computerized prescriber order entry (CPOE) reported fewer harmful errors. According to the 2003 data, automated dispensing devices (ADDs) were implicated in almost 9,000 medication error events with 1.3 percent of those errors leading to patient harm.
From United States Pharmacopeia :
Computer Entry a Leading Cause of Medication Errors in U.S. Health Systems
Percentage of Reported Errors Steadily Increased from 1999 to 2003
The United States Pharmacopeia (USP) reported today that despite the perception that technology is the panacea that will improve patient safety and reduce medication errors, nearly 20 percent of hospital and health system medication errors reported to USP’s MEDMARXSM program in 2003 involved computerization or automation. However, facilities that have implemented computerized prescriber order entry (CPOE) reported fewer harmful errors. According to the 2003 data, automated dispensing devices (ADDs) were implicated in almost 9,000 medication error events with 1.3 percent of those errors leading to patient harm.
These findings are part of USP’s annual report summarizing the data collected by MEDMARX, the national medication error reporting system operated by USP. The report, MEDMARX 5th Anniversary Data Report: A Chartbook of 2003 Findings and Trends 1999-2003 , provides a comprehensive analysis of 235,159 medication error records voluntarily reported by 570 hospitals and health care facilities nationwide. The report includes five-year trend analysis of records for 1999-2003, as well as a focus on technology-related errors.
Medication Errors Associated with Computerization
Errors that result from using a computer can occur in any phase of the medication use process: prescribing, transcribing/documenting, dispensing, administering, and monitoring. Computer Entry (CE) errors occur when incorrect or incomplete information, such as patient names, or drug doses, or laboratory test results, is entered into a computer system. According to USP’s data, most CE errors occurred in either the transcribing/documenting phase or dispensing phase of the medication use process.
”It would seem logical that applying computer technology to the medication use process would have a significant positive impact in preventing medication errors,” said Diane Cousins, R.Ph., vice president of USP’s Center for the Advancement of Patient Safety. ”Yet, depending on the computer’s design or user competence, new points of potential errors can emerge. Health care providers need to be focused and vigilant in their use of computers.”
In 2003, CE errors were the fourth leading cause of medication errors according to MEDMARX data. CE errors have steadily increased and represent 11.5 percent of all MEDMARX records from 1999 through 2003. The data indicate that nearly three-quarters of all CE errors occur after an order is written but before the medication is administrated to the patient. Other significant findings associated with CE errors:
? Performance deficit was the most frequently reported Cause of Error in CE. A Performance deficit is a Cause of Error in which the health care practitioner has the required skills and knowledge to execute a task but errs nonetheless.
? Distractions were the leading Contributing Factor, accounting for 56.5 % (3,293) of errors associated with CE. ? Wrong dose errors occurred more frequently in CE records compared to overall 2003 data, indicating that there was a higher occurrence of selecting the incorrect dose when a computer entry system was involved in processing the drug order after it was written.
Computerized Prescriber Order Entry (CPOE)
When a licensed prescriber incorrectly or incompletely enters a medication order into a computer, it is characterized as a CPOE error. Over 99 percent of these errors did not reach or harm patients, suggesting that CPOE helps to reduce the risk of harmful errors.
The average number of reported errors due to wrong dose and wrong dosage form (e.g., tablet vs. injection) was slightly higher for facilities using CPOE. However, the total number of errors per 100,000 doses dispensed was nearly the same as in non-CPOE facilities.
The occurrence of CPOE errors exposes design flaws, poor or insufficient clinical decision support rules, inadequate training, and user resistance, which have, individually or collectively, undermined the potential benefits of a CPOE system. A CPOE system should simplify the creation of a medication order by a health care practitioner. But excessive CPOE alerts, inadequate decision support, or confusing product formulation selections can also cause the prescriber to err.
Other significant findings associated with CPOE errors include:
? Dosing errors (extra dose, wrong dose, and omission) accounted for 48.5% of CPOE errors.
? Knowledge deficit was the most frequently reported additional Cause of Error, indicating the person using CPOE was unfamiliar with its functionality and made an error when entering orders.
Automated Dispensing Device (ADD) Errors
ADDs are drug storage and dispensing devices located in patient care areas of health care facilities. Their use in hospitals and health systems has grown during the past decade, and today ADDs are in use in more than half of U.S. hospitals. ADDs are the tenth leading cause of medication errors, with nearly 70 percent of these errors being either a wrong dose or a wrong drug error.
Significant findings associated with ADD errors include:
? The largest portion (44 percent) of ADD-related errors reported were due to errors in the dispensing phase of the medication use process.
? Wrong doses were reported more than twice as often (52.9 percent versus 23.9 percent) when ADD-related errors were compared to the overall 2003 MEDMARX data,
? Drug distribution system errors, including not only ADDs, but also stocking, cart filling, and transport of medicines, were the leading causes of ADD-related errors reported in 55% of the records.
The media may receive a copy of the 2003 data report by sending an e-mail to [email protected] . Others may purchase the report by going to http://store.usp.org .
MEDMARX is the nation’s largest database of medication errors and contains more than 800,000 records. Between January 1, 1999 and December 31, 2003, over 700 healthcare facilities contributed to this database. MEDMARX is a national, Internet-accessible, anonymous reporting database that hospitals and health care systems use to track and trend adverse drug events, which includes medication errors. Hospitals and health care systems participate in MEDMARX voluntarily. USP created MEDMARX to help health care facilities understand the causes of adverse drug events and the factors that contribute to them in order to improve patient care and safety.