title: Understanding the nature of medication errors in an ICU with a computerized physician order entry system.
abstract: OBJECTIVE
  We investigated incidence rates to understand the nature of medication errors potentially introduced by utilizing a computerized physician order entry (CPOE) system in the three clinical phases of the medication process: prescription, administration, and documentation.
  
  
  METHODS
  Overt observations and chart reviews were employed at two surgical intensive care units of a 950-bed tertiary teaching hospital. Ten categories of high-risk drugs prescribed over a four-month period were noted and reviewed. Error definition and classifications were adapted from previous studies for use in the present research. Incidences of medication errors in the three phases of the medication process were analyzed. In addition, nurses' responses to prescription errors were also assessed.
  
  
  RESULTS
  Of the 534 prescriptions issued, 286 (53.6%) included at least one error. The proportion of errors was 19.0% (58) of the 306 drug administrations, of which two-thirds were verbal orders classified as errors due to incorrectly entered prescriptions. Documentation errors occurred in 205 (82.7%) of 248 correctly performed administrations. When tracking incorrectly entered prescriptions, 93% of the errors were intercepted by nurses, but two-thirds of them were recorded as prescribed rather than administered.
  
  
  CONCLUSIONS
  The number of errors occurring at each phase of the medication process was relatively high, despite long experience with a CPOE system. The main causes of administration errors and documentation errors were prescription errors and verbal order processes. To reduce these errors, hospital-level and unit-level efforts toward a better system are needed.
authors.affiliation: Department of Nursing, Inha University, Incheon, Republic of Korea; Harvard Medical School, Boston, MA, United States of America; Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, United States of America.
authors.forename: Insook
authors.initials: I
authors.lastname: Cho
authors.affiliation: Department of Nursing, Inha University Hospital, Incheon, Republic of Korea.
authors.forename: Hyeok
authors.initials: H
authors.lastname: Park
authors.affiliation: Department of Nursing, Inha University, Incheon, Republic of Korea; Department of Nursing, Inha University Hospital, Incheon, Republic of Korea.
authors.forename: Youn Jeong
authors.initials: YJ
authors.lastname: Choi
authors.affiliation: Department of Nursing, Inha University, Incheon, Republic of Korea; Department of Nursing, Inha University Hospital, Incheon, Republic of Korea.
authors.forename: Mi Heui
authors.initials: MH
authors.lastname: Hwang
authors.affiliation: Harvard Medical School, Boston, MA, United States of America; Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, United States of America; Partners Healthcare Systems, Inc., Wellesley, MA, United States of America.
authors.forename: David W
authors.initials: DW
authors.lastname: Bates
mesh_terms: D007362:Intensive Care Units / Q000706:statistics & numerical data*; D050316:Medical Order Entry Systems / Q000706:statistics & numerical data*; D008508:Medication Errors / Q000145:classification / Q000517:prevention & control* / Q000706:statistics & numerical data