Identifying and Quantifying Medication Errors: Evaluation of Rapidly Discontinued Medication Orders Submitted to a Computerized Physician Order Entry System
- Ross Koppela,b,
- Charles E Leonardb,c,
- A Russell Localiob,c,
- Abigail Cohenb,c,
- Ruthann Autenb,c,
- Brian L Stromb,c,d
- aDepartment of Sociology, University of Pennsylvania, Philadelphia, PA
- bDepartment of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA
- cCenter for Education and Research on Therapeutics, University of Pennsylvania School of Medicine, Philadelphia, PA
- dDepartment of Medicine (General Medicine Division), Department of Pharmacology, University of Pennsylvania School of Medicine, Philadelphia, PA
- Correspondence: Ross Koppel, Ph.D. 813 Pardee Lane, Wyncote, PA 19095; e-mail: <rkoppel{at}sas.upenn.edu>
- Received 6 July 2007
- Accepted 19 March 2008
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.
