Data entry is a top cause of medication errors

Training and design are seen as keys to reducing electronic prescribing errors.

By — Posted Jan. 24, 2005

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Computerized prescribing systems might cut the quantity and severity of medication mistakes, but they can't eliminate them entirely, said patient safety experts who reviewed the U.S. Pharmacopeia's 5th annual study of medication error reports.

The study of the more than 235,000 error reports submitted in 2003 by 570 health care facilities was the largest ever by USP. And as the number of reported errors goes up, the percentage that causes patient harm has gone down. But the findings that generated the most discussion are those indicating that electronic prescribing is creating new types of errors.

"Computer entry" was the fourth-leading cause of errors, accounting for 13% (27,711) of the medication errors reported in 2003. In contrast, illegible or unclear handwriting was the 15th-leading cause, and accounted for 2.9% (6,134) of reported errors.

"It could be expected that handwriting would move down the list as computerization becomes more widely implemented, but what is surprising is that a new type of error is replacing handwriting," said Diane Cousins, vice president for USP Center for the Advancement of Patient Safety. "I was shocked to see computer entry moving up to fourth. The fact that it's moving up is a disturbing thing."

What this also shows, some experts said, is that implementing electronic systems requires physician input on design and extensive training with frequent refresher courses.

"It doesn't mean it's unsafe to use technology, it means we have human beings making computer errors," said Institute for Safe Medication Practices Executive Director Allen Vaida, PharmD. "When you use IT correctly, it helps reduce errors that reach patients, but there are still errors."

Use as directed

Suzanne Delbanco, PhD, CEO of The Leapfrog Group, which promotes electronic prescribing as a primary tool for patient safety, agreed.

"[Computer physician order entry] done right is still the gold standard," she said. "But CPOE in and of itself is not a solution. Training and execution of design are critical."

Patient safety expert Nancy C. Elder, MD, MPH, a University of Cincinnati associate professor of family medicine, noted that the reports collected by USP came mainly from hospitals. But she said the types of computer-related errors reported -- such as entering prescriptions for the wrong patient -- are similar to those committed in outpatient settings.

Less than 13% of the participating facilities were outpatient centers, but primary care physicians can still learn from the study, said Kwabena O.M. Adubofour, MD. "Most outpatient encounters end with a drug being prescribed or being continued," said Dr. Adubofour, medical director of the Fifth Street Medical Center in Stockton, Calif. "Physicians need to be made aware of the potential for medication errors in primary care, given the fact that patients are taking their meds without supervision."

Dr. Adubofour, whose report "Strategies to Reduce Medication Errors in Ambulatory Practice" was published in the December 2004 issue of the Journal of the National Medical Association, said an electronic system has to be customized for the doctors who use it. It takes time to work out the bugs, he said, but that isn't a good reason for not using the technology.

"We need to look at CPOE as a journey -- not a destination," Dr. Adubofour said. "It will take a number of years with continued updates for any institution to have a system that is near perfect, i.e., a system that thinks like a clinician, or nurse, or pharmacist. ... We will get the issues raised in the report by the U.S. Pharmacopeia resolved. It is just a matter of time."

Cousins said the good news was that errors related to electronic prescribing are less likely to lead to patient harm.

Defined as an error caused by incomplete or incorrect entry of a medication by a licensed prescriber, USP added "computerized prescriber order entry" to its list of "cause of error variables" in May of 2003. It received more than 7,000 reports of this type, but only 0.1% of these led to patient harm. In comparison, the percentage of patient harm associated with all errors reported in 2003 was 1.51%.

USP is a nongovernmental, standard-setting organization with some 400 members, including medical and pharmacy colleges, and professional, scientific and trade associations.

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The chief reasons

In its fifth annual study, the U.S. Pharmacopeia found these to be the leading causes of medication errors reported in 2003:

Cause of errorErrorsPercent
Performance deficit81,20438.2%
Procedures/protocol not followed38,93718.3%
Transcription inaccurate/omitted28,02913.2%
Computer entry27,71113.0%
Documentation inadequate or lacking25,49012.0%
Knowledge deficit24,09911.3%
Written order11,2235.3%
Drug distribution system problem9,2204.3%
Dispensing device problem8,8624.2%
Incorrect entry by prescriber7,0293.3%
System safeguards inadequate or lacking6,8673.2%
Calculation error6,2642.9%
Illegible or unclear handwriting6,1342.9%
Inadequate monitoring5,4862.6%
Dosage form confusion4,6872.2%
Fax/scanner problems3,9651.9%

Note: Multiple causes were given for some errors, so sum of percentages is more than 100. For performance deficit category, total indicates user had required knowledge to operate computer but made an error in the execution of the action. For knowledge deficit category, total indicates user was unaware of computer system's functionality. Source: United States Pharmacopeia

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Most errors don't cause harm

Each year, the U.S. Pharmacopeia analyzes reports of medication errors sent in voluntarily by health care facilities from across the nation. In 2003, the 235,159 error reports it received from 570 facilities were broken down this way:

No errorCircumstances had capacity
for error
No harm
Error did not reach patient90,29638.4%
No harm
Error reached patient,
but didn't cause harm
No harm
Error required monitoring
or intervention to confirm it
didn't cause harm
Error/HarmError contributed to or
resulted in temporary harm
and required intervention
Error/HarmError contributed to or
resulted in temporary harm
needing initial or prolonged
Error/HarmError contributed to or
resulted in permanent harm
Error/HarmError required intervention
necessary to sustain life
DeathError contributed to or
resulted in patient death

Source: U.S. Pharmacopeia

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External links

Press release on the U.S. Pharmacopeial Convention's fifth annual report on medication errors (link)

"Overview of the Leapfrog Group Evaluation Tool for Computerized Physician Order Entry," December 2001, in pdf (link)

"Strategies to Reduce Medication Errors in Ambulatory Practice," Journal of the National Medical Association, December 2004, in pdf (link)

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