R E V I E W S & A N A LY S E S Omission of High-Alert Medications: A Hidden Danger Matthew Grissinger, RPh, FISMP, FASCP INTRODUCTION Manager, Medication Safety Analysis A drug omission can be defined as an event in which an appropriate medication is not Dalia Alghamdi, BSc Pharm, MSc HCPM Patient Safety Analyst provided to a patient, either because the medication has not been prescribed or has not Pennsylvania Patient Safety Authority been administered. There are clinical reasons why patients may not receive medications (e.g., when patients are designated “nothing by mouth” [NPO] status, when patients are off of the unit for tests or otherwise unavailable to take their medications). ABSTRACT The impact of a drug omission varies from insignificant to severe harm, depending on A drug omission occurs when a patient the medications and the patient’s medical conditions.1 Suboptimal treatment may also does not receive a medication that has lead to an increased length of stay. The frequent occurrence of drug omissions may been ordered or when a medication has both reflect and contribute to significant organizational inefficiency. not been ordered despite being appro- priate for an underlying condition. Over Drug omissions can occur during any stage of the medication-use process. Medications 2,700 medication errors categorized as may be omitted from initial medication lists obtained upon admission, prescribers may drug omissions involving more than 500 omit a drug when writing or entering orders, orders for medications may not be tran- different medications were reported to scribed onto a paper medication administration record (MAR), pharmacy personnel the Pennsylvania Patient Safety Authority may neglect to enter an order into the pharmacy computer system or may not deliver from January 1, 2013, through April medications to patient care areas on time, or nurses may fail to administer the medica- 30, 2013. Antibiotics (19.7%) and tion as prescribed. Based on an analysis of other medication error reporting programs, medications used for respiratory therapy drug omissions are frequently the most common type of medication error reported.2 (11.5%) were the most common medica- While there are studies showing that omissions are a leading type of medication error, tions cited in reports. More than 21% of there are few studies that reveal the reasons why they are occur. Green et al. studied reports involved at least one high-alert admission prescription charts, recording all drugs prescribed but not given in the first medication. A majority of omissions with 48 hours, along with the reason given for omission during the administration process. high-alert medications occurred during Twenty percent of prescriptions did not reach the intended patient, affecting 17% of the administration process (52.9%), the patients.1 Warne et al. examined the documentation of medication administra- followed by occurrence during the tion in medical and surgical patients to determine the point prevalence of medication transcription (22.9%) and prescribing omissions, finding that 79% of patients did not receive at least one dose for one drug (12.0%) processes. Most administra- during one admission and that the average number of medication omissions was tion omissions involved a medication 2.5 per patient.3 Other studies examining omissions have shown various rates of occur- intended to be given by an intravenous rence ranging from 1.1% to 58%.4,5 McMillan et al. and Dean et al. suggest that up to (IV) route (32.9%) or by other injectable 57% of missed medications could be detrimental6 or even life-threatening.7 routes (38.0%). The most commonly Analysis of drug omissions reported to the Pennsylvania Patient Safety Authority has cited types of omissions involving an IV identified where in the medication-use process these events occur, the reasons why high-alert medication included IV infu- medications were not prescribed or administered to patients, and the factors that may sions that were not started, IV tubing have contributed to these events. The analysis focused on high-alert medications,8 as that was not connected or was clamped, these drugs pose an increased risk of patient harm when involved in medication errors. and IV infusion pumps that were not turned on or were turned off. Risk reduc- METHODS tion strategies include developing a Analysts queried the Authority’s Pennsylvania Patient Safety Reporting System (PA-PSRS) consistent administration process for IV database for reports assigned the event type “medication error/omissions.” Based on medication setup, tracing IV lines, and another analysis of medication error reports that showed that drug omissions were the using healthcare technology fully and most common medication error event type, analysts queried a short duration of time.2 properly. (Pa Patient Saf Advis 2014 The query yielded 2,787 medication error reports that had been submitted to the Dec;11[4]:149-55.) Authority from January 1, 2013, through April 30, 2013, representing 16.1% of all medi- Corresponding Author cation events submitted (N = 17,276) and the most common type of medication error Matthew Grissinger reported in that time period. Vol. 11, No. 4—December 2014 Pennsylvania Patient Safety Advisory Page 149 ©2014 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S RESULTS Table. Top 10 Medications Involved in Drug Omission Events Reported to the Pennsylvania Patient Safety Authority from January 1, 2013, through April 30, 2013 (n = 994, 35.7% Categorization of the reports by harm of total reports) score, which is adapted from the National Coordinating Council for Medication MEDICATION NO. OF REPORTS % OF TOTAL Error Reporting and Prevention (NCC REPORTS* MERP) harm index,9 shows that 88.6% Insulin† 140 5.0 (n = 2,469) of the drug omission events Albuterol sulfate and ipratropium reached the patient (harm score = C to I) bromide 137 4.9 and that only 0.2% (n = 5) of the events Vancomycin 134 4.8 resulted in patient harm (harm score = E to I). According to the NCC MERP harm Albuterol 110 3.9 index, when a patient does not receive the Multiple medications 101 3.6 medication (i.e., an error of omission), Heparin† 100 3.6 the error is considered to have reached the patient.9 Hydration 78 2.8 Overall, 91 unique care areas were asso- Warfarin † 72 2.6 ciated with drug omissions. The most CeFAZolin 63 2.3 common units implicated in drug omis- sions included medical-surgical units Enoxaparin sodium† 59 2.1 (17.8%, n = 496), respiratory care– * Total drug omission reports (N = 2,787) † diagnostic/therapeutic units (8.0%, A high-alert medication n = 223), and rehabilitation units (6.8%, such as thrombotic or hyperglycemic In order to identify prescribing and n = 189). Omissions that take place dur- events. Due to this potential for harm, the administration errors, Ghaleb et al. con- ing prescribing (e.g., failure to prescribe analysis focuses on the omission of high- ducted a prospective review of medication a medication) are not necessarily a reflec- alert medications. charts as well as a prospective observation tion of the care area but may simply of nurses preparing and administering reflect the location of the patient at the ANALYSIS drugs. They found that 5% of the errors time of the omission. were omissions—either the drug was not More than half of the reports involved Omission of High-Alert available on the patient care unit or the the elderly population (65 years old or Medications nurse did not realize the drug was due for above) (51.8%, n = 1,445), followed by When studying admission prescription the patient.10 the adult population (18 to 64 years) charts, Green et al. identified the two A retrospective review of electronic medi- (41.2%, n = 1,147). Only 7.0% (n = 195) dominant reasons for medications not cation administration records (eMARs),11 of the reports involved the pediatric being given to patients: (1) the medica- which included adult hospitalized patients population (less than 18 years of age) tion was not available in the patient care who were ordered pharmacologic venous More than 500 different medications were area (38% of omissions) or (2) the patient thromboembolism (VTE) prophylaxis cited in omission reports (see the Table), was designated NPO status (32% of with unfractionated heparin or enoxapa- with antibiotics mentioned in 19.7% omissions). In 10% of cases, the patient rin over a seven-month period, measured (n = 549) of the reports and medications refused the medication; in 19% of cases, the proportion of ordered doses of VTE used for respiratory therapy involved in no reason for omission was given; and prophylaxis not administered. Heparin 11.5% (n = 320) of the reports. Over in 0.3% of cases, the patient was away regimens had higher rates of nonad- 21% (n = 593) of the reports involved at from the unit. There was no correlation ministration and documented patient least one high-alert medication. While between the day of the week admitted refusal than enoxaparin. For example, omissions may be viewed as events that and the number of medication omis- while medicine floors had significantly normally would not result in harm to a sions related to drug unavailability in the higher overall rates of nonadministra- patient, the omission of high-alert medica- patient care area. In particular, weekends tion and documented patient refusals, tions, such as anticoagulants (e.g., heparin, (when the pharmacy runs at a reduced heparin regimens had significantly higher warfarin) or hypoglycemic agents staff level) were no different from week- nonadministration and documented (e.g., insulin), could result in serious harm days (when the pharmacy is fully staffed).1 refusal rates than enoxaparin regimens Page 150 Pennsylvania Patient Safety Advisory Vol. 11, No. 4—December 2014 ©2014 Pennsylvania Patient Safety Authority The patient was on a heparin drip. It TYPES OF OMISSIONS [was determined] that the prior nurse had changed the IV tubing and never Following are descriptions of how drug omissions involving intravenous (IV) high-alert medications occurred during the administration node, as reported to the Pennsylva- connected it to patient. [The tubing nia Patient Safety Authority from January 1, 2013 through April 30, 2013: was] under the patient’s bed. The patient had a KVO that had been — IV accidentally discontinued turned off but never disconnected, — IV bag empty which made me think that it was — IV drug delivery system vial (e.g., Add-Vantage™) not activated the heparin tubing connected to the — IV hung but not infusing (e.g., IV pump never turned on or was turned off) patient. When I realized this, I recon- — IV line occluded nected the heparin tubing, kept the rate the same, and placed an order to — IV medication not sent with patient upon transfer to another unit recheck the aPTT [activated partial — IV not connected thromboplastin time]. I also notified — IV not hung the charge RN. — IV not started The nurse hung a new TPN [total — IV stopped parenteral nutrition] bag with lipids. — IV tubing clamped when it should have been infusing Two hours later, the nurse assessed — Nurse distracted the line and found the tubing clamped and fluid leaking from the — Problem with IV solution bag (e.g., bag defective) lipids port, which was loose. Pump — Wrong IV solution hung and ordered solution not given did not alarm, indicating problem with line. Hourly blood sugar was lower than previous result. The nurse on medicine floors. Likewise, on virtually Omissions”). The most common types did not open IV clamp when new every floor that had substantial use of of omissions involving an IV high-alert bag hung. both heparin and enoxaparin regimens medication included IVs that were not ordered every 12 hours, these rates were started (7.0%, n = 22), IV tubing that was Patient admitted with a third-degree significantly higher for the heparin regi- not connected (3.2%, n = 10), IV tubing heart block, hypotension, and MI mens. Nearly 12% of ordered doses of that was clamped (2.9%, n = 9), and the [myocardial infarction]. She was on pharmacologic VTE prophylaxis were not IV infusion pump not being turned on or 0.5 mcg/kg/minute of Levophed™ administered, nearly identical to rates being turned off (2.2%, n = 7). [norepinephrine] and was receiving reported in other studies.11,12 hemodialysis in her room. When her Following are examples of reports of drug Levophed beeped to KVO, the dialy- omission errors occurring during the sis nurse in the room turned the drip Administration Node administration process: off instead of notifying the nurse that A majority (52.8%, n = 313) of the drug [The patient] only had a PCA the bag needed to be changed. omission reports that involved high-alert [patient-controlled analgesia pump] medications (n = 593) describe omissions that took place during the administra- running with KVO [keep vein open] Transcription Node fluids. [The patient] had an order for The transcription node comprised the tion process. Predominantly, these a heparin drip to be restarted. After second most common (22.9%, n = 136) events involved a medication intended assessing the patient and review- node where reported omissions of high- to be given by an intravenous (IV) route ing the orders, I noticed the nurse alert medications originated. For this (32.9%, n = 103) or other injectable route reviewed an order in the afternoon analysis, the transcription node included (e.g., subcutaneous, intramuscular [IM]) stating to restart a heparin drip in any process that involved the communica- (38.0%, n = 119). two hours, per vascular. I called down tion of an order after the medication was Most event descriptions did not provide to see if this order had been discontin- prescribed and before a medication was enough information to determine what ued since there was no heparin drip dispensed or obtained and administered. may have led to the omission of the with the patient. The heparin drip The most common types of omissions medication. Analysis did reveal a variety was then started at night. included orders that were not transcribed of types of drug omissions (see “Types of Vol. 11, No. 4—December 2014 Pennsylvania Patient Safety Advisory Page 151 ©2014 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S and/or orders that were missed (52.9%, process for anticoagulants involved prob- Examples of these events include n = 72) and orders that were not trans- lems with the reordering process (44.4%, the following: mitted (e.g., faxed or scanned) to the n = 20), such as prescribers not being A 60-year-old inpatient was admit- pharmacy or other care area (16.2%, called to write new orders, orders being ted status post right femoral rodding. n = 22). discontinued and not rewritten, or orders The patient was ordered Arixtra® Following are examples of reports of drug not being written due to the unavailability [fondaparinux sodium] 7.5 mg omission errors occurring during the tran- of lab results. [treatment dose], but when the nurse scription node: Following are examples of reports of drug rescheduled the medication, the order Methotrexate order incorrectly listed omission errors occurring during the pre- date ended and dropped off the active on emergency department’s medica- scribing node: orders. The patient missed doses for tion reconciliation form as [two Patient was on Coumadin® [warfarin two days. On the third day, it was doses daily]. [Order was] clarified to sodium] for atrial fibrillation. The discovered the patient missed two weekly. However, when transcribed, patient missed two days of Coumadin doses, and the Arixtra was reordered. the two doses were transcribed to secondary to the medication not being Physician wanted to restart patient’s begin one week apart. Patient missed ordered. This was noticed on the day heparin drip at night. He entered the [one] dose (seeking additional clari- of discharge back to outside facility. order through CPOE as a nursing fication of schedule) and potentially Medication ordered for outside facility. communication instead of choosing would have missed [a second] dose if Patient did not receive evening dose the heparin drip and picking a start the error was not detected. of warfarin because the INR [inter- time. Since this order was a nursing While doing the 24-hour chart check, national normalized ratio] was not communication, pharmacy did not it was noted that an order was writ- available. Order for warfarin was receive any notification to restart ten on the VTE risk assessment sheet placed by the physician’s assistant, the heparin drip. Pharmacy was for Lovenox® [enoxaparin] 40 mg but recent order set change does not not aware that there was nursing subcutaneous once daily. The order prompt nonphysicians to order an INR communication that contained a was never faxed to the pharmacy, and for warfarin [on the first day of admin- medication order until nursing con- in turn, the patient missed two doses istration]. Previously, this “ONCE” tacted pharmacy. of the medication. Once discovered, INR was prechecked in the order set. An order was entered for warfarin the order was immediately faxed, veri- At a 658-bed academic hospital with com- 2 mg po [by mouth] once daily and fied on the MAR, and signed off. puterized prescriber order entry (CPOE) validated by pharmacy. Because order that lacked electronic medication admin- start time by the physician is after Prescribing Node istration charting, a retrospective manual [the prescribed time of administra- The third most common node involved in chart audit compared expected (from tion], the first occurrence for order reported omissions of high-alert medica- CPOE) and actual timing of medication became [the following day]. The tions was the prescribing node (12.0%, administrations.13 The analysis showed patient missed the dose. n = 71), which, for this analysis, included that the most common event involved any activity pertaining to the ordering dose omissions (12.6%). The authors RISK REDUCTION STRATEGIES or reordering of a medication. The most concluded that while inpatient CPOE The drug omission events submitted common classes of high-alert medication orders are legible and can be conveyed to the Authority reveal the complex mentioned in omissions occurring during electronically to nurses and the pharmacy, nature and large variety of factors that this node were anticoagulants (63.4%, unit-based medication administrations contribute to drug omissions. While n = 45), insulin (12.7%, n = 9), and TPN do not consistently occur as ordered. As medication omissions are often thought therapy (7.0%, n = 5). Medication classes more facilities use CPOE systems to enter to occur or originate primarily during such as anticoagulants and TPN are often drug orders, drug omission events may the administration process, omission ordered with the expectation that a new originate from issues associated with these errors were identified in all phases of the order will be written daily or an order is systems. Of the events in the prescribing medication-use process. Unfortunately, automatically stopped and the medication phase reported to the Authority (n = 71), most of the PA-PSRS event reports did would not be administered until the next nine (12.7%) involved electronic systems not explicitly describe the errors nor new order is written. The most frequently and eight (11.3%) involved anticoagulants. disclose the causes and contributing fac- noted breakdown in the prescribing tors linked to the errors; however, these Page 152 Pennsylvania Patient Safety Advisory Vol. 11, No. 4—December 2014 ©2014 Pennsylvania Patient Safety Authority reports, observations from the Institute typically do not serve as order noti- Transcribing and for Safe Medication Practices (ISMP), and fication vehicles, so the nurse must Communicating Orders the medical literature suggest strategies actively look elsewhere for new medi- ISMP has observed that the following strat- that healthcare facilities may consider to cation orders. egies can be used to identify contributing decrease the risk of drug omissions. — eMAR technology can help reduce factors of omissions related to the tran- the risk of drug omissions through scribing and communication of orders: Use Healthcare Technology the use of signals or alerts to remind — Ensure that there is a standardized Fully and Properly nursing when a dose is due. and consistent process in place for Although not always easy to implement, The author also noted that errors due to reviewing the previous day’s MAR technological innovations can enhance a wrong or erroneous actual medication and validating whether any new patient safety.14 Paper transcription omis- order could potentially increase with the medications have been ordered prior sions may be avoided with CPOE systems implementation of BCMA and eMAR to transcribing information to the that integrate with eMARs and pharmacy technology.15 The current lag between new record. computer systems. The need to identify ordering and administration (predomi- — Standardize the way in which pending orders in a paper chart and then nantly for “stat” or “now” orders) allows nursing personnel designate a dis- transcribe the order to a paper or eMAR time for corrections when faulty orders continued order and how new orders as well as send the order to the pharmacy are detected, whereas the window for cor- are added to the MAR or eMAR. If can be eliminated. rections would be greatly reduced with using a paper-based system, provide Technology could help to reduce omis- BCMA and eMAR technology replacing nurses with the ability to print a sions in the following ways:15 the slower manual transcription process. new MAR at any high-risk transition — A bar-code medication administra- The use of well-designed standard order point in the patient’s stay (e.g., new tion (BCMA) system or eMAR could sets for high-alert medications, whether admission, transfer, postoperative). help to detect omissions caused by electronic or paper formats, have the — If a paper-based ordering and docu- simple oversights when the drug was potential to reduce variation and unin- mentation system is currently in use, administered but administration was tentional oversight through standardized convene a group of staff involved in not documented or when admin- formatting and clear, predictable presenta- these processes to determine the risk istration was intentionally held or tion of orders.16 For example, order sets points in identifying when orders are omitted but neither the omission that include medications appropriate to handwritten and need to be further nor the reason were charted. How- the condition and available in a facility’s transcribed and communicated, in ever, some unexplained omissions formulary may help to reduce the inci- part to avoid repeated duplication are likely to continue even with dence of missed orders. and possible error. real-time BCMA and eMAR systems. However, medication administration — Establish a process to track and trend For example, nurses might fail to discrepancies are likely to persist even any identified MAR omissions. For give a scheduled dose or chart a after implementing CPOE and other example, in organizations with phar- reason when they unexpectedly have electronic systems unless interventions macy-generated MARs, nurses on to attend to a life-threatening emer- are made to address workarounds and the night shift perform a verification gency for a patient in a room nearby usability issues. In fact, while historical process as soon as the new MARs to the index patient. studies have shown error reduction up to are delivered to the units. Inform — BCMA and eMAR systems could 81%, CPOE systems can also lead to error pharmacy of any discrepancies and reduce some omissions that occur risk.17 Therefore, these systems need to allow time for pharmacists to review because the nurse is unaware of the be continually examined and enhanced. and investigate reported variances, order. New orders are readily avail- Many factors such as system, user, organi- make corrections to the MAR if able in the eMAR, thus eliminating zational, and environmental attributes, as needed, and communicate changes the need to monitor and track down well as level of support from others, can back to the nursing unit. Reports of multiple paper charts. However, these impact successful adoption of technol- MAR discrepancies due to omissions systems would not impact errors ogy.18 Technical design of the system is should continue to be collected and of omission that occur due to the also important, as staff acceptance and used for safety and quality initiatives nurse’s urgent duties elsewhere. In use of technology can be impacted by the in order to identify patterns, trends, addition, BCMA and eMAR systems technology’s usability and usefulness.19 Vol. 11, No. 4—December 2014 Pennsylvania Patient Safety Advisory Page 153 ©2014 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S causes, and contributing factors, as port. The Joint Commission recommends the Authority reveals that these events well as to help create solutions. tracing all lines back to their origin before take place across the continuum of the — Develop a standardized workflow connecting any devices or infusions.21 In medication-use process. While the major- for pharmacists performing order addition, nurses could hang the high-alert ity of reported events took place during entry in which they self-check sheets solution, prepare it for infusion, and the administration process, omissions can of orders for omissions. Many then have another nurse independently originate in all nodes, even with the use of computer systems include electronic validate the original order, the patient’s healthcare technology. Developing more notation capabilities that can be lev- identification, the dose and concentra- effective technology, using that technology eraged for this purpose. tion, the insertion site (route), and the fully and properly, developing a consistent pump or channel setting before initiating administration process for IV medication IV Administration of High-Alert the infusion.20 setup, tracing IV lines, and standard- Medications Affixing a label with the name of the izing policies and procedures can help to Developing a consistent process, includ- drug to each IV line, at the end closest to reduce omission errors. ing standardized policies and procedures, the patient and above each channel on The reports submitted to the Authority for IV medication setup to support identi- the pump, may help prevent omissions reveal the incidence of errors, the sever- fication of IV lines that are not connected with infusions and may also help prevent ity of errors, and the frequency with to the patients despite being placed errors if tubing has to be detached from which high-alert medications are not within an infusion pump, IV pumps that patients during procedures, imaging, or administered to the patient. Using this are not turned on, and IV tubing that is transfers. While this additional labeling information to raise professional staff clamped can help reduce the risk of IV alone should not be used to identify the awareness of the prevalence of omission infusion omissions. ISMP suggests that medication, the labels can aid practitio- errors is likely to be helpful, as a lack of “when using multiple channel pumps, ners in line tracing and independent research and data in the field has contrib- nurses should handle just one IV solution double checks. uted to low appreciation of this common at a time.”20 Physically tracing the line can threat to safety. It is important to note help ensure that the correct channel has CONCLUSION that more research must be done to deter- been used to program the infusions as mine the exact causes of drug omissions Analysis of drug omission reports involv- well as confirm that the IV line has been and the best risk reduction strategies for ing high-alert medications submitted to connected to the patient at the correct drug omission. NOTES 1. Green CJ, Du-Pre P, Elahi N, et al. Omis- 6. McMillan TW, Hamley J, Pullar T. Com- 10. Ghaleb MA, Barber N, Franklin BD, et sion after admission: failure in prescribed pliance with prescribed medicines in al. The incidence and nature of prescrib- medications being given to inpatients. general medical and surgical wards. Br J ing and medication administration errors Clin Med 2009 Dec;9(6):515-8. Clin Pract 1994 Nov-Dec;48(6):302-3. in paediatric inpatients. Arch Dis Child 2. Hicks RW, Becker SC, Cousins DD, eds. 7. Dean BS, Allan EL, Barber ND, et 2010 Feb;95(2):113-8. MEDMARX data report. A report on the al. Comparison of medication errors 11. Shermock KM, Lau BD, Haut ER, et relationship of drug names and medication in an American and a British hospi- al. Patterns of non-administration of errors in response to the Institute of Medicine’s tal. Am J Health Syst Pharm 1995 Nov ordered doses of venous thromboem- call for action. Rockville (MD): Center for 15;52(22):2543-9. bolism prophylaxis: implications for the Advancement of Patient Safety, US 8. Institute for Safe Medication Practices. novel intervention strategies [online]. Pharmacopeia; 2008. ISMP’s list of high-alert medications PLoS ONE 2013 Jun 14 [cited 2014 Jul 3. Warne S, Endacott R, Ryan H, et al. Non- [online]. 2012 [cited 2014 Apr 21]. http:// 29]. http://www.plosone.org/article/ therapeutic omission of medications in www.ismp.org/Tools/institutionalhigh info%3Adoi%2F10.1371%2Fjournal. acutely ill patients. Nurs Crit Care 2010 Alert.asp pone.0066311 May-Jun;15(3):112-7. 9. National Coordinating Council for Medi- 12. Fanikos J, Stevens LA, Labreche M, et al. 4. Lawler C, Welch SA, Brien JAE. Omitted cation Error Reporting and Prevention. Adherence to pharmacological thrombo- medication doses: frequency and severity. NCC MERP index for categorizing medi- prophylaxis orders in hospitalized patients. J Pharm Pract Res 2004 Sep;34(3):174-7. cation errors [online]. 2001 Feb [cited Am J Med 2010 Jun;123(6):536-41. 5. Kester L, Stoller JK. Prevalence and causes 2014 Jun 29]. http://www.nccmerp.org/ 13. FitzHenry F, Peterson JF, Arrieta M, of medication errors: a review. Clin Pulm medErrorCatIndex.html et al. Medication administration dis- Med 2003 Nov;10(6):322-6. crepancies persist despite electronic ordering. J Am Med Inform Assoc 2007 Nov-Dec;14(6):756-64. Page 154 Pennsylvania Patient Safety Advisory Vol. 11, No. 4—December 2014 ©2014 Pennsylvania Patient Safety Authority 14. Grissinger M, Cohen H, Vaida AJ. Using 17. Koppel R, Metlay JP, Cohen A, et al. Role 20. Cohen MR. Preventing medication errors technology to prevent medication errors. of computerized physician order entry related to drug delivery devices. Chapter Chapter 15. In: Cohen MR, ed. Medica- systems in facilitating medication errors. 12. In: Cohen MR, ed. Medication errors. tion errors. 2nd ed. Washington (DC): JAMA 2005 Mar 9;293(10):1197-203. 2nd ed. Washington (DC): American American Pharmacists Association; 2007. 18. Holden RJ. What stands in the way Pharmacists Association; 2007. 15. Barker KN. Ensuring safety in the use of technology-mediated patient safety 21. Joint Commission. Tubing misconnec- of automated medication dispensing improvements?: a study of facilitators tions—a persistent and potentially deadly systems. Am J Health Syst Pharm 1995 Nov and barriers to physicians’ use of elec- occurrence [online]. Sentinel Event Alert 1;52(21):2445-7. tronic health records. J Patient Saf 2011 2006 Apr 3 [cited 2014 Jan 31]. http:// 16. Institute for Safe Medication Practices. Dec;7(4):193-203. www.jointcommission.org/assets/1/18/ ISMP’s guidelines for standard order sets 19. Carayon P, Cartmill R, Blosky MA, et SEA_36.PDF [online]. 2010 [cited 2014 Aug 14]. http:// al. ICU nurses’ acceptance of electronic www.ismp.org/tools/guidelines/standard health records. J Am Med Inform Assoc ordersets.pdf 2011 Nov-Dec;18(6):812-9. Vol. 11, No. 4—December 2014 Pennsylvania Patient Safety Advisory Page 155 ©2014 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 11, No. 4—December 2014. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2014 by the Pennsylvania Patient Safety Authority. 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