title: Identifying and quantifying medication errors: evaluation of rapidly discontinued medication orders submitted to a computerized physician order entry system.
abstract: All methods of identifying medication prescribing errors are fraught with inaccuracies and systematic bias. A systematic, efficient, and inexpensive way of measuring and quantifying prescribing errors would be a useful step for reducing them. We ask if rapid discontinuations of prescription-orders--where physicians stop their orders within 2 hours--would be an expedient proxy for prescribing errors? To study this we analyzed CPOE-system medication orders entered and then discontinued within 2 hours. We investigated these phenomena in real time via interviews with corresponding ordering physicians. Each order was also independently reviewed by a clinical pharmacist or physicians. We found that of 114 rapidly discontinued orders by 75 physicians, two-thirds (35 of 53, PPV = 66; 95% CI = 53-77) of medication orders discontinued within 45 minutes were deemed inappropriate (overdose, underdose, etc.). Overall, 55% (63 of 114; 95% CI = 46-64%) of medication orders discontinued within 2 hours were deemed inappropriate. This measure offers a rapid, constant, inexpensive, and objective method to identify medication orders with a high probability of error. It may also serve as a screening and teaching mechanism for physicians-in-training.
authors.affiliation: Department of Sociology, University of Pennsylvania, Philadelphia, PA, USA. rkoppel@sas.upenn.edu
authors.forename: Ross
authors.initials: R
authors.lastname: Koppel
authors.forename: Charles E
authors.initials: CE
authors.lastname: Leonard
authors.forename: A Russell
authors.initials: AR
authors.lastname: Localio
authors.forename: Abigail
authors.initials: A
authors.lastname: Cohen
authors.forename: Ruthann
authors.initials: R
authors.lastname: Auten
authors.forename: Brian L
authors.initials: BL
authors.lastname: Strom
mesh_terms: D004347:Drug Interactions; D006801:Humans; D007407:Interviews as Topic; D050316:Medical Order Entry Systems; D008508:Medication Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D004364:Pharmaceutical Preparations / Q000008:administration & dosage; D010818:Practice Patterns, Physicians'; D012189:Retrospective Studies; D013997:Time Factors
chemical_list: D004364:Pharmaceutical Preparations