title: Indication alerts intercept drug name confusion errors during computerized entry of medication orders.
abstract: BACKGROUND
  Confusion between similar drug names is a common cause of potentially harmful medication errors. Interventions to prevent these errors at the point of prescribing have had limited success. The purpose of this study is to measure whether indication alerts at the time of computerized physician order entry (CPOE) can intercept drug name confusion errors.
  
  
  RESULTS
  A retrospective observational study of alerts provided to prescribers in a public, tertiary hospital and ambulatory practice with medication orders placed using CPOE. Consecutive patients seen from April 2006 through February 2012 were eligible if a clinician received an indication alert during ordering. A total of 54,499 unique patients were included. The computerized decision support system prompted prescribers to enter indications when certain medications were ordered without a coded indication in the electronic problem list. Alerts required prescribers either to ignore them by clicking OK, to place a problem in the problem list, or to cancel the order. Main outcome was the proportion of indication alerts resulting in the interception of drug name confusion errors. Error interception was determined using an algorithm to identify instances in which an alert triggered, the initial medication order was not completed, and the same prescriber ordered a similar-sounding medication on the same patient within 5 minutes. Similarity was defined using standard text similarity measures. Two clinicians performed chart review of all cases to determine whether the first, non-completed medication order had a documented or non-documented, plausible indication for use. If either reviewer found a plausible indication, the case was not considered an error. We analyzed 127,458 alerts and identified 176 intercepted drug name confusion errors, an interception rate of 0.14±.01%.
  
  
  CONCLUSIONS
  Indication alerts intercepted 1.4 drug name confusion errors per 1000 alerts. Institutions with CPOE should consider using indication prompts to intercept drug name confusion errors.
authors.affiliation: Department of Medicine, University of Illinois at Chicago (UIC), Chicago, Illinois, United States of America; Department of Pharmacy Practice UIC, Chicago, Illinois, United States of America.
authors.forename: William L
authors.initials: WL
authors.lastname: Galanter
authors.affiliation: Department of Pharmacy Practice UIC, Chicago, Illinois, United States of America.
authors.forename: Michelle L
authors.initials: ML
authors.lastname: Bryson
authors.affiliation: Department of Medicine, University of Illinois at Chicago (UIC), Chicago, Illinois, United States of America.
authors.forename: Suzanne
authors.initials: S
authors.lastname: Falck
authors.affiliation: College of Medicine, University of Illinois, Chicago, Illinois, United States of America.
authors.forename: Rachel
authors.initials: R
authors.lastname: Rosenfield
authors.affiliation: Department of Medicine, University of Illinois at Chicago (UIC), Chicago, Illinois, United States of America.
authors.forename: Marci
authors.initials: M
authors.lastname: Laragh
authors.affiliation: Department of Pharmacy Administration UIC, Chicago, Illinois, United States of America.
authors.forename: Neeha
authors.initials: N
authors.lastname: Shrestha
authors.affiliation: Department of Medicine, Harvard University, Boston, Massachusetts, United States of America.
authors.forename: Gordon D
authors.initials: GD
authors.lastname: Schiff
authors.affiliation: Department of Communication Studies and Center for Communication and Health, Northwestern University, Chicago, Illinois, United States of America.
authors.forename: Bruce L
authors.initials: BL
authors.lastname: Lambert
mesh_terms: D020000:Decision Support Systems, Clinical; D006801:Humans; D008508:Medication Errors / Q000517:prevention & control; D010820:Physicians; D012189:Retrospective Studies