title: Chemotherapy prescribing errors: an observational study on the role of information technology and computerized physician order entry systems.
abstract: BACKGROUND
  Chemotherapy administration is a high-risk process. Aim of this study was to evaluate the frequency, type, preventability, as well as potential and actual severity of outpatient chemotherapy prescribing errors in an Oncology Department where electronic prescribing is used.
  
  
  METHODS
  Up to three electronic prescriptions per patient record were selected from the clinical records of consecutive patients who received cytotoxic chemotherapy between January 2007 and December 2008. Wrong prescriptions were classified as incomplete, incorrect or inappropriate. Error preventability was classified using a four-point scale. Severity was defined according to the Healthcare Failure Mode and Effect Analysis Severity Scale.
  
  
  RESULTS
  Eight hundred and thirty-five prescriptions were eligible. The overall error rate was 20%. Excluding systematic errors (i.e. errors due to an initially faulty implementation of chemotherapy protocols into computerized dictionaries) from the analysis, the error rate decreased to 8%. Incomplete prescriptions were the majority. Most errors were deemed definitely preventable. According to error presumptive potential for damage, 72% were classified as minor; only 3% had the potential to produce major or catastrophic injury. Sixty-eight percent were classified as near misses; adverse drug events had no or little effect on clinical outcome.
  
  
  CONCLUSIONS
  Chemotherapy prescribing errors may arise even using electronic prescribing. Although periodic audits may be useful to detect common errors and guide corrective actions, it is crucial to get the computerized physician order entry system and set-ups correct before implementation.
authors.forename: Marianna
authors.initials: M
authors.lastname: Aita
authors.forename: Ornella
authors.initials: O
authors.lastname: Belvedere
authors.forename: Elisa
authors.initials: E
authors.lastname: De Carlo
authors.forename: Laura
authors.initials: L
authors.lastname: Deroma
authors.forename: Federica
authors.initials: F
authors.lastname: De Pauli
authors.forename: Lorena
authors.initials: L
authors.lastname: Gurrieri
authors.forename: Angela
authors.initials: A
authors.lastname: Denaro
authors.forename: Loris
authors.initials: L
authors.lastname: Zanier
authors.affiliation: Department of Oncology, S, Maria della Misericordia, University Hospital, Udine, Italy. fasola.gianpiero@aoud.sanita.fvg.it.
authors.forename: Gianpiero
authors.initials: G
authors.lastname: Fasola
mesh_terms: D000368:Aged; D000970:Antineoplastic Agents / Q000008:administration & dosage / Q000627:therapeutic use; D064420:Drug-Related Side Effects and Adverse Reactions / Q000453:epidemiology / Q000517:prevention & control; D055695:Electronic Prescribing / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D050316:Medical Order Entry Systems / Q000706:statistics & numerical data*; D008508:Medication Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D008875:Middle Aged; D012189:Retrospective Studies
chemical_list: D000970:Antineoplastic Agents