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In Pennsylvania, medication mistakes attributed to health IT

In Pennsylvania, health IT contributed to 889 medication mistakes in hospitals over a six month period from January 1, 2016, to June 30, 2016.

During this time period the Pennsylvania Patient Safety Authority found that the majority of these medication mistakes were due to errors in hospitals’ computerized physician order entry (CPOE) and EHR systems. These medication mistakes included dose omission (13.8%), wrong dose or over dosage (10.9%), and extra dose (10.7%), according to a report by the Pennsylvania Patient Safety Authority. Of the 889 medication mistakes made, 69.2% reached the patient, and eight of the 889 medication mistakes resulted in patient harm, the report said.

While the majority of medication mistakes occurred due to errors with CPOE and EHR systems, these mistakes spanned across all health IT components which also include pharmacy systems, electronic medication administration record (eMAR), clinical documentation systems, clinical decision support systems, and bar coded medication administration (BCMA) system, the report found.

CPOE and EHR errors

“The CPOE system was cited most often as an HIT component that contributed to the top three error event types,” the report said.

The report found that half of the 889 medication mistakes cited the CPOE system as a contributing factor while EHR components — including the clinical documentation and clinical decision support systems — contributed to 13.8% of the errors.

Of the errors reported concerning the EHR system, 56 were identified as communication issues with the majority of those 56 errors (69.6%) being due to prescriber free-texting instructions in the order comments field.

“More than a third of the free-text orders (35.9%) specified when to hold or discontinue the medication, which is a workaround that prescribers may use instead of modifying the end date within the CPOE medication order,” the report said.

The report concludes that ongoing health IT system surveillance and remedial interventions are needed.

“Oftentimes, failures in the HIT systems are attributed to human error, which hinders the investigation into secondary causes of the patient safety event such as limitations in software interoperability, usability, and workflow processes,” the report said. “The interaction between clinician and software is a key component that is to be taken into consideration when trying to improve the safety of HIT.”