IT no cure-all for prescription errors

For the third time this year, scholars have published an article describing how errors can occur when doctors use automated systems to prescribe medicine for hospital patients.

The newest article, published in the July-August issue of the Journal of the American Medical Informatics Association (JAMIA), tells how an elderly patient suffering from several ailments including kidney failure was treated for potassium deficiency. Due to a series of errors, the patient received more than three times the maximum allowable dosage of potassium intravenously over about two days.

The authors reconstructed the series of errors to discover what went wrong. They concluded that “this medical error was the product of failure in interaction among human and systems agents.” Inadequate training, poorly designed screens and a lack of warnings for system users were primarily to blame, they wrote.

Dr. David Brailer, the national coordinator for health information technology at the Department of Health and Human Services, and other HHS officials often suggest that medicine-prescribing applications, known as computer-based prescription order entry (CPOE) systems, are a good starting point for hospitals and doctors’ offices when they decide to use clinical IT.

CPOE systems can verify that the medicine is appropriate for the patient’s condition, that the dosage is correct, that the patient is not known to be allergic to it and that no unexpected interaction with other medications is likely to occur.

“It’s been proven that this technology really enhances safety,” said Jan Horsky, a doctoral student in medical informatics at Columbia University and the lead author of the JAMIA paper. Several studies have found that CPOE systems can reduce the number of medication errors by as much as 73 percent, while also eliminating paperwork.

However, as CPOE becomes more widely used, it is becoming clear that the technology is not a panacea. The authors of the JAMIA paper recommended several improvements in the system they were analyzing, which was developed in house at New York Presbyterian Hospital in New York City.

Horsky said the hospital had subsequently implemented all the recommendations made by the paper’s authors.

The current issue of the Journal of Biomedical Informatics includes a special section on CPOE and medication errors. Some commentators make the point that it’s unrealistic to expect a new CPOE system to work perfectly when it’s first installed. Continuous monitoring and improvements should be expected, they say.

Earlier this year, articles about CPOE errors appeared in the Journal of the American Medical Association and the Archives of Internal Medicine.


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