Patient Safety and Quality

Nearly 1 in 10 outpatient computerized prescriptions contains errors

Electronic prescribing (e-prescribing) has helped reduce medication errors and adverse drug events (ADEs) in a variety of health care settings, including the outpatient environment. However, computer-generated prescriptions can also introduce a new level of errors. What’s more, they cannot prevent all of the errors normally made with paper prescriptions. A new study found that about 1 in 10 computer-generated prescriptions had at least 1 error. In addition, a third of these errors had the potential for harm.

Massachusetts researchers reviewed 3,850 computer-generated prescriptions from a retail outpatient pharmacy chain located in three States. During a 4-week period, the pharmacy sent all computer-generated prescriptions to the study’s research group. They were then reviewed by an independent clinical review panel. A total of 452 (11.7 percent) prescriptions were found to have 466 errors in them. More than a third of these errors (35.0 percent) were classified as potential ADEs. None of the ADEs were considered life-threatening; they were deemed either significant (58.3 percent) or serious (41.7 percent). The majority of medication errors involved anti-infectives, while nervous-system drugs accounted for the most ADEs.
Image of a pill bottle

Different computerized systems generated different types of medication errors.

Omitted information such as dose, frequency, and duration, was the most common reason for error. Omitting a dose was responsible for 35 percent of all potential ADEs. Based on their findings, the researchers offer several strategies to reduce errors associated with computer-generated prescriptions. These include designing functions to prevent omitted information (called forcing functions), incorporating maximum dose checking in drug-decision support features, and using system calculators to resolve quantity errors. The study was supported in part by the Agency for Healthcare Research and Quality (HS16970). See "Errors associated with outpatient computerized prescribing systems," by Karen C. Nanji, M.D., M.P.H., Jeffrey M. Rothschild, M.D., M.P.H., Claudia Salzberg, M.S., and others in the June 29, 2011 online edition of the Journal of the American Medical Informatics Association.

Research Activities, November 2011: Patient Safety and Quality: Nearly 1 in 10 outpatient computerized prescriptions contains errors