Identifying and Quantifying Medication Errors: Evaluation of Rapidly Discontinued Medication Orders Submitted to a Computerized Physician Order Entry System

Ross Koppel, Charles E. Leonard, A. Russell Localio, Abigail Cohen, Ruthann Auten, Brian L. Strom

Research output: Contribution to journalArticlepeer-review

33 Scopus citations

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.

Original languageEnglish (US)
Pages (from-to)461-465
Number of pages5
JournalJournal of the American Medical Informatics Association
Volume15
Issue number4
DOIs
StatePublished - Jul 2008

All Science Journal Classification (ASJC) codes

  • Health Informatics

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