Abstract
Background Previous research developed a new method for locating prescribing errors in rapidly
discontinued electronic medication orders. Although effective, the prospective design
of that research hinders its feasibility for regular use.
Objectives Our objectives were to assess a method to retrospectively detect prescribing errors,
to characterize the identified errors, and to identify potential improvement opportunities.
Methods Electronically submitted medication orders from 28 randomly selected days that were
discontinued within 120 minutes of submission were reviewed and categorized as most
likely errors, nonerrors, or not enough information to determine status. Identified
errors were evaluated by amount of time elapsed from original submission to discontinuation,
error type, staff position, and potential clinical significance. Pearson's chi-square
test was used to compare rates of errors across prescriber types.
Results In all, 147 errors were identified in 305 medication orders. The method was most
effective for orders that were discontinued within 90 minutes. Duplicate orders were
most common; physicians in training had the highest error rate (p < 0.001), and 24 errors were potentially clinically significant. None of the errors
were voluntarily reported.
Conclusion It is possible to identify prescribing errors in rapidly discontinued medication
orders by using retrospective methods that do not require interrupting prescribers
to discuss order details. Future research could validate our methods in different
clinical settings. Regular use of this measure could help determine the causes of
prescribing errors, track performance, and identify and evaluate interventions to
improve prescribing systems and processes.
Keywords
adverse drug event - medication errors - patient safety - electronic health records
- error management and prevention
