medication errors
Schnipper JL et al, J Am Med Inform Assoc, 2012
Objective
To determine the effects of a personal health record (PHR)-linked medications module on medication accuracy and safety.
Design
From September 2005 to March 2007, we conducted an on-treatment sub-study within a cluster-randomized trial involving 11 primary care practices that used the same PHR. Intervention practices received access to a medications module prompting patients to review their documented medications and identify discrepancies, generating ‘eJournals’ that enabled rapid updating of medication lists during subsequent clinical visits.
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Published:
3 May 2012 |
Keyword(s): Accuracy, Electronic Health Records, Medication Errors, Medication Safety, Personal Health Records, United States
van der Sijs H et al, J Am Med Inform Assoc, 13(2)
Many computerized physician order entry (CPOE) systems have integrated drug safety alerts. The authors reviewed the literature on physician response to drug safety alerts and interpreted the results using Reason’s framework of accident causation. In total, 17 papers met the inclusion criteria. Drug safety alerts are overridden by clinicians in 49% to 96% of cases. Alert overriding may often be justified and adverse drug events due to overridden alerts are not always preventable. A distinction between appropriate and useful alerts should be made.
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Published:
15 December 2005 |
Keyword(s): Alerts, CPOE, Drug Safety, Medication Errors
Russ AL et al, International Journal of Medical Informatics, 81(4)
Purpose
Few studies have examined prescribers’ interactions with medication alerts at the point of prescribing. We conducted an in situ, human factors investigation of outpatient prescribing to uncover factors that influence the prescriber–alert interaction and identify strategies to improve alert design.
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Published:
1 February 2012 |
Keyword(s): Alerts, CPOE, Electronic Prescribing, Human-computer Interaction, Medication Errors, United States
Vázquez Vela V et al, European Journal of Hospital Pharmacy, 19(2)
Background
A high proportion of the information about the patients’ medication from the electronic health record contains some error. The importance of these errors has not been studied.
Purpose
To analyse the importance of the errors contained in the Electronic Health Record EHR relating to patients’ usual medication.
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Published:
18 March 2012 |
Keyword(s): Electronic Health Records, Medication Errors
Remen VM, Grimsmo A. International Journal of Medical Informatics, 80(11)
Background
Information deficits contribute to medical errors. Hence several efforts to develop electronic communication systems to facilitate a flow of information between health care providers have been attempted, including initiatives to develop regional or national electronic patient summaries.
Objectives
To study information access and information needs in inpatient emergency departments, and how clinicians in these departments handle deficits in available information.
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Published:
26 September 2011 |
Keyword(s): Electronic patient summaries, Emergency medical service, Health Information Systems, Information Sharing, Medical Errors, Medication Errors, Norway
Connor AJ et al, European Journal of Ophthalmology, 21(5)
Purpose.
Prescription and drug errors are common causes of adverse clinical events, posing a significant risk to safe patient care. Although there has been a movement to increase the use of electronic prescribing, concerns over feasibility suggest that improving the design of written prescriptions to minimize missing information may still be worthwhile. This retrospective cross-sectional study examined the effect on prescription completeness of electronic prescriptions and adding information prompts to written prescriptions. We hypothesized that electronic prescription would be superior to written prescriptions on prescription completeness and the inclusion of information prompts in written prescriptions would result in increased recording of the prompted information.
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Published:
10 January 2011 |
Keyword(s): Electronic Prescribing, Medication Errors, Patient Safety
Flannigan C, McAloon J. Resuscitation, 2011
OBJECTIVE:
To compare the use of a drugs calculator on a smartphone with use of the British National Formulary for Children (BNFC) for accuracy, speed and confidence of prescribing in a simulated paediatric emergency.
DESIGN:
28 doctors and 7 medical students in a paediatric department of a District General Hospital, were asked to prescribe both a dopamine infusion and an adrenaline infusion for a hypotensive child. For one calculation they used the BNFC as their reference source and for the other they used the ‘PICU Calculator’ on the iPhone.
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Published:
23 July 2011 |
Keyword(s): Electronic Prescribing, Emergencies, Medication Errors, Smart Phone, UK
Wetterneck TB et al, J Am Med Inform Assoc, 2011
Objective
To evaluate the incidence of duplicate medication orders before and after computerized provider order entry (CPOE) with clinical decision support (CDS) implementation and identify contributing factors.
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Published:
29 July 2011 |
Keyword(s): Clinical decision support, CPOE, Implementation, Intensive care unit, Medication Errors, United States
Radecki RP, Sittig DF. JAMA, 306(1)
Since publication of To Err Is Human, electronic health records (EHRs) and related health information technologies have been promoted as means to improve patient safety. This promise remains largely unfulfilled. For instance, whereas EHRs with clinical decision support (CDS) interventions integrated into computerized physician order entry (CPOE) have measurably improved clinicians’ performance on process metrics, their effect on patient outcomes remains unconfirmed.
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Published:
6 July 2011 |
Keyword(s): Checklist, Communication, Electronic Health Records, Medical Errors, Medication Errors, Patient Identification Systems, PCOE, Risk, Safety, United States
Nanji KC et al, J Am Med Inform Assoc, 2011
Objective
To report the frequency, types, and causes of errors associated with outpatient computer-generated prescriptions, and to develop a framework to classify these errors to determine which strategies have greatest potential for preventing them.
Materials and methods
This is a retrospective cohort study of 3850 computer-generated prescriptions received by a commercial outpatient pharmacy chain across three states over 4 weeks in 2008. A clinician panel reviewed the prescriptions using a previously described method to identify and classify medication errors. Primary outcomes were the incidence of medication errors; potential adverse drug events, defined as errors with potential for harm; and rate of prescribing errors by error type and by prescribing system.
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Published:
29 June 2011 |
Keyword(s): Electronic Prescribing, Medication Errors, Outpatients, United States
Redwood S et al, BMC Medical Informatics and Decision Making, 11(1)
BACKGROUND:
Even though electronic prescribing systems are widely advocated as one of the most effective means of improving patient safety, they may also introduce new risks that are not immediately obvious. Through the study of specific incidents related to the processes involved in the administration of medication, we sought to find out if the prescribing system had unintended consequences in creating new errors. The focus of this study was a large acute hospital in the Midlands in the United Kingdom, which implemented a Prescribing, Information and Communication System (PICS).
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Published:
12 May 2011 |
Keyword(s): Electronic Prescribing, Hospitals, Implementation, Medication Errors, Patient Safety
Grossman JM, AHRQ, Research Brief No. 20
Hoping to reduce medication errors and contain health care costs, policy makers are promoting electronic prescribing through Medicare and Medicaid financial incentives. Many e-prescribing systems provide electronic access to important information—for example, medications prescribed by physicians in other practices, patient formularies and generic alternatives—when physicians are deciding what medications to prescribe. However, physician practices with e-prescribing face challenges using these features effectively, according to a new qualitative study by the Center for Studying Health System Change (HSC) funded by the Agency for Healthcare Research and Quality (AHRQ).
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Published:
May 2011 |
Keyword(s): Data Management, Electronic Health Records, Electronic Prescribing, Medication Errors, United States
Khajouei R et al, International Journal of Medical Informatics, 2011
Objectives
To study the satisfaction of end-users of a computerized physician order entry (CPOE) system concerning ease of use and the effect on users’ workflow, efficiency, and medication safety and to seek users’ opinions regarding required improvements of the system. Usability evaluation had shown that this system, which was in use for almost a decade, contained a number of severe usability problems. So another objective of the study was to determine whether there was a direct relation between user satisfaction and the results of a usability evaluation of the system.
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Published:
17 March 2011 |
Keyword(s): CPOE, Efficiency, Medication Errors, Medication Systems, Netherlands, Usability, User Satisfaction, User-Computer Interface, Workflow
Fischer SH et al, J Am Med Inform Assoc, 17(6)
Medication errors are a major source of morbidity and mortality. Inadequate laboratory monitoring of high-risk medications after initial prescription is a medical error that contributes to preventable adverse drug events. Health information technology (HIT)-based clinical decision support may improve patient safety by improving the laboratory monitoring of high-risk medications, but the effectiveness of such interventions is unclear. Therefore, the authors conducted a systematic review to identify studies that evaluate the independent effect of HIT interventions on improving laboratory monitoring for high-risk medications in the ambulatory setting using a Medline search from January 1, 1980 through January 1, 2009 and a manual review of relevant bibliographies.
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Published:
1 November 2010 |
Keyword(s): Clinical decision support, Health Information Technology, Medication Errors, Systematic Review
Wakefield DS et al, American Journal of Health-System Pharmacy, 67(23)
Purpose
The implementation of a telepharmacy service to provide round-the-clock medication order review by pharmacists is described.
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Published:
1 December 2010 |
Keyword(s): CPOE, Electronic Health Records, Hospitals, Medication Errors, Pharmacists, telepharmacy, United States
Gandhi TK et al, Journal of General Internal Medicine, 20(9)
BACKGROUND:
Medication errors are common among inpatients and many are preventable with computerized prescribing. Relatively little is known about outpatient prescribing errors or the impact of computerized prescribing in this setting.
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Published:
September 2005 |
Keyword(s): Ambulatory Care, Electronic Prescribing, Medication Errors, Outpatients, United States
Mattison MLP et al. Archives of Internal Medicine, 170(15)
Background
Potentially inappropriate medication (PIM) use in hospitalized older patients is common. Our objective was to determine whether a computerized provider order entry (CPOE) drug warning system can decrease orders for PIMs in hospitalized older patients.
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Published:
9 August 2010 |
Keyword(s): Alerts and Reminders, CPOE, Elderly, Hospitals, Medication Errors, United States
Nemeth C, Cook R. Journal of Biomedical Informatics, 38(4)
We agree with the point that Dr. Koppel and coauthors make in their JAMA paper ‘‘The Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors.’’ There really is a problem with healthcare IT and the problem is not an artifact of the particular system that the paper’s research covered. It is intriguing that this is considered news.
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Published:
20 June 2005 |
Keyword(s): CPOE, Decision Support Systems, Health Information Technology, Medical Informatics, Medication Errors, Medication Systems, United States
Furukawa MF et al, Health Affairs, 27(3)
Health information technology (IT) is regarded as an essential tool to improve patient safety, and a range of initiatives to address patient safety are under way. Using data from a comprehensive, national survey from HIMSS Analytics, we analyzed the extent of health IT adoption for medication safety in U.S. hospitals in 2006.
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Published:
May 2008 |
Keyword(s): Adoption, Health Information Technology, Hospitals, Medical Informatics, Medication Errors, Medication Safety, United States
Poon EG et al, N Engl J Med, 362(18)
Background
Serious medication errors are common in hospitals and often occur during order transcription or administration of medication. To help prevent such errors, technology has been developed to verify medications by incorporating bar-code verification technology within an electronic medication-administration system (bar-code eMAR).
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Published:
6 May 2010 |
Keyword(s): Adverse Drug Events, Barcode, Hospitals, Medication Errors, Safety, United States
