Prevention of Pediatric Medication Errors by Hospital Pharmacists and the Potential Benefit of Computerized Physician Order Entry
- 1 January 2007
- journal article
- Published by American Academy of Pediatrics (AAP) in PEDIATRICS
- Vol. 119 (1), e77-e85
- https://doi.org/10.1542/peds.2006-0034
Abstract
OBJECTIVES. The purpose of this work was to characterize medication errors and adverse drug events intercepted by a system of pediatric clinical pharmacists and to determine whether the addition of a computerized physician order entry system would improve medication safety.METHODS. The study included 16938 medication orders for 678 admissions to the pediatric units of a large academic community hospital. Pediatric clinical pharmacists reviewed medication orders and monitored subsequent medication use. Medication errors and adverse drug events were identified by daily review of documentation, voluntary reporting, and solicitation. Each potentially harmful medication error was judged whether or not it was intercepted and, if not, whether it would have been captured by a computerized physician order entry system.RESULTS. Overall, 865 medication errors occurred, corresponding with a rate of 5.2 per 100 medication orders. A near-miss rate of 0.96% and a preventable adverse drug event rate of 0.09% were observed. Overall, 78% of potentially harmful prescribing errors were intercepted; however, none of the potentially harmful errors occurring at administration was intercepted and accounted for 50% of preventable adverse drug events. A computerized physician order entry system could capture additional potentially harmful prescribing and transcription errors (54%–73%) but not administration errors (0% vs 6%).CONCLUSIONS. A system of pediatric clinical pharmacists effectively intercepted inpatient prescribing errors but did not capture potentially harmful medication administration errors. The addition of a computerized physician order entry system to pharmacists is unlikely to prevent administration errors, which pose the highest risk of patient injury.Keywords
This publication has 22 references indexed in Scilit:
- Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry SystemPEDIATRICS, 2005
- The impact of hospitalwide computerized physician order entry on medical errors in a pediatric hospitalJournal of Pediatric Surgery, 2005
- The Epidemiology of Prescribing ErrorsArchives of Internal Medicine, 2004
- Impact of Computerized Physician Order Entry on Clinical Practice in a Newborn Intensive Care UnitJournal of Perinatology, 2004
- Identifying Adverse Drug Events: Development of a Computer-based Monitor and Comparison with Chart Review and Stimulated Voluntary ReportJournal of the American Medical Informatics Association, 1998
- Systems analysis of adverse drug events. ADE Prevention Study GroupJAMA, 1995
- Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study GroupJAMA, 1995
- Incidence and preventability of adverse drug events in hospitalized adultsJournal of General Internal Medicine, 1993
- The Nature of Adverse Events in Hospitalized PatientsThe New England Journal of Medicine, 1991
- Incidence of Adverse Events and Negligence in Hospitalized PatientsThe New England Journal of Medicine, 1991