R E V I E W S & A N A LY S E S Prescribing Errors that Cause Harm Briana B. Rider, PharmD INTRODUCTION Patient Safety Analyst Studies have found that a large number of medication errors originate in the prescrib- Michael J. Gaunt, PharmD ing phase of the medication use process.1,2 Bates et al. found that 56% of preventable Sr. Medication Safety Analyst events originated in the prescribing stage,1 while Leape and colleagues found that Matthew Grissinger, RPh, FISMP, FASCP Manager, Medication Safety Analysis drug-drug interactions, failure to act on a test, wrong choice, and wrong dose errors Pennsylvania Patient Safety Authority occurred most frequently in the prescribing stage.2 Reported rates of prescribing errors range from 3.13 to 62.4 errors per 1,000 medication orders.3-5 However, a prescribing error is less likely to reach the patient and cause harm than errors that occur in sub- ABSTRACT sequent phases of the medication use process, because there are more opportunities Errors that occur in the prescribing to intercept the error in the transcribing, dispensing, administering, and monitoring phase of the medication use process phases. Despite this, some prescribing errors make their way through the entire medica- are less likely to reach the patient and tion use process, reach the patient, and cause harm. cause harm because of the opportunity Historically, many medication prescribing errors have been associated with illegible to intercept the error in the phases of handwriting, the use of error-prone abbreviations, incomplete orders, and incorrectly transcribing, dispensing, administering, transcribed verbal orders. A 2004 study by Bobb et al. found that the most common and monitoring. However, some pre- medication error types for clinically significant prescribing errors were wrong dose scribing errors make their way through (39.2%), wrong frequency (20.2%), nomenclature (9.4%), drug allergy (6.4%), wrong the entire medication use process, reach medication (6.4%), medication duplication (5.5%), and omission (4.7%). The most the patient, and cause harm. A query of common drug classes for these prescribing errors were anti-infectives, cardiovascu- the Pennsylvania Patient Safety Reporting lar agents, and opioids; and nearly two-thirds of the errors occurred upon hospital System (PA-PSRS) database revealed 811 admission.3 Serious Events (harm score E through I) associated with reported prescribing Pennsylvania Patient Safety Authority analysts conducted an analysis of Serious Events errors that occurred from July 2004 associated with reported medication prescribing errors; that is, those that reached the through June 2016. Nearly 5% (4.7%, n patient and caused harm. Analysts sought to characterize contributing factors and iden- = 38) of these errors required interven- tify appropriate system-based risk reduction strategies. tion to sustain life or contributed to or resulted in the patient’s death. The most METHODS common types of events reported were Analysts queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) data- wrong dose/overdosage (32.2%, n = base for Serious Events resulting from medication errors, harm score E through I as 261), monitoring error/documented adapted from the National Coordinating Council for Medication Error Reporting allergy (14.5%, n = 118), dose omis- and Prevention (NCC MERP),6 associated with the prescribing phase, that occurred sion (14.3%, n = 116), and wrong from July 2004 through June 2016. This query yielded 837 event reports. Twenty-six patient (4.4%, n = 36). Recommended reports (3.1%) were excluded from final analysis because the error likely did not origi- system-based risk reduction strate- nate with the prescribing phase (e.g., an error occurred because the infusion pump for gies include optimizing computerized an appropriately prescribed medication was programmed incorrectly at the point of prescriber order entry with clinical deci- administration). A total of 811 event reports remained for final analysis. sion support to facilitate screening for The medication name, patient care area, event type, event description, phase(s) of the drug-related problems; and developing medication use process, and harm score, adapted from the NCC MERP harm index,6 well-designed standard order sets; (Pa were provided by the reporting facility. In reports in which a medication name data Patient Saf Advis 2016 Sep;13[3]:81-91.) field was left blank or incomplete but the name was provided in the event description, Corresponding Author an analyst adjusted the medication name field appropriately. Reports were categorized Matthew Grissinger into type of prescribing error, drug class(es) involved, and order type (e.g., handwrit- ten, verbal, computerized prescriber order entry [CPOE]). Reports of unsafe orders Scan this code that were given verbally and then transcribed into an electronic order entry system by with your mobile another practitioner were coded as verbal orders, when that distinction was possible. device’s QR reader to access Error reports were further evaluated to identify contributing factors and were assessed the Authority's for the likelihood that the error could be intercepted by CPOE and clinical decision toolkit on this support (CDS) with basic functionality. Classification of the likelihood that errors topic. Vol. 13, No. 3—September 2016 Pennsylvania Patient Safety Advisory Page 81 ©2016 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S could be intercepted by CPOE and CDS Figure 1. Harm Scores for Serious Events Associated with Prescribing Errors, as and possibly prevented was adapted Reported to the Pennsylvania Patient Safety Authority, July 2004 through June from previously published categories.3,7 2016 (N = 811) Prescribing errors related to illegible handwriting, incomplete orders, drug- NUMBER OF REPORTS allergy interactions, and wrong dose 600 formulation were categorized as likely to 549 (67.7%) be intercepted by CPOE and CDS, as described by Bobb et al.3 500 RESULTS Results were categorized by harm score; 400 the majority (67.7%, n = 549 of 811) of the Serious Events were reported as an error that occurred that may have con- 300 tributed to or resulted in temporary harm to the patient and required intervention 218 (26.9%) (harm score = E). Nearly 5% (n = 38) 200 either required intervention necessary to sustain life (e.g., cardiovascular and respiratory support [harm score= H]) or 100 contributed to or resulted in the patient’s death (harm score = I; see Figure 1). 18 (2.2%) 20 (2.5%) 6 (0.7%) Nearly 40% (n = 319) of the events involved 0 opioids, anticoagulants, and insulin—high- E F G H I MS16602 alert medications that pose an increased HARM SCORE risk of patient harm when involved in medication errors.8 Figure 2 shows the five Figure 2. Most Common Drug Classes Involved in Serious Events Associated with most common drug classes involved in the Prescribing Errors, as Reported to the Pennsylvania Patient Safety Authority, July reported events. 2004 through June 2016 (N = 811) Four event types accounted for 65.5% (n = 531) of submitted prescribing error DRUG CLASS reports (see Figure 3). Nearly one-quarter (21.5%, n = 174) of the Opioid* 143 (17.6%) serious prescribing errors in the present analysis were judged as likely to be inter- Antibiotic 95 (11.7%) cepted and therefore possibly preventable if CPOE with CDS were used. Errors asso- ciated with the following event types and Anticoagulant* 88 (10.9%) contributing factors were judged as likely to be intercepted: drug/allergy interactions Insulin* 88 (10.9%) (14.5%, n = 118), illegible handwriting (3.8%, n = 31), incomplete orders (2.2%, n = 18), and wrong dose formulation Anticonvulsant 58 (7.2%) (0.9%, n = 7). See Table for examples of 0 30 60 90 120 150 prescribing errors rated as likely, possibly, MS16603 or unlikely to be intercepted by CPOE NUMBER OF REPORTS with CDS. * High-alert medication Page 82 Pennsylvania Patient Safety Advisory Vol. 13, No. 3—September 2016 ©2016 Pennsylvania Patient Safety Authority Figure 3. Event Types Involving Serious Events Associated with Prescribing Errors, Wrong Dose/Overdosage Errors as Reported to the Pennsylvania Patient Safety Authority, July 2004 through June Nearly one-third (32.2%, n = 261 of 811) 2016 (N = 811) of the Serious Events were categorized by facilities as wrong dose/overdosage events. Of these reports, 22.6% (n = 59 of 261) involved opioids, 16.5% (n = 43) involved Wrong dose/ insulin, and 9.2% (n = 24) involved anti- overdosage coagulants (see Figure 4). 280 261 (34.5%) (32.2%) Monitoring error/ Naloxone, a reversal agent for opioids, documented allergy was administered in 71.2% (n = 42 of 59) of the reported wrong dose/ Dose omission overdosage errors involving opioids. HYDROmorphone was the medication 118 Wrong patient most frequently involved (52.5%; n = 31 116 (14.5%) of 59) in reported opioid wrong dose/ 36 All other event types (14.3%) overdosage errors, and of these, 61.3% MS16604 (4.4%) (n = 19 of 31) involved an intravenous (IV) HYDROmorphone dose of 1 mg or more and 41.9% (n = 13 of 31) involved an IV HYDROmorphone dose of 2 mg or more. An IV HYDROmorphone dose of 1 mg is equivalent to approximately 7.5 mg of IV morphine and is the current Figure 4. Most Common Drug Classes Involved in Serious Wrong Dose/ maximum starting dose for an opioid- Overdosage Events Associated with Prescribing Errors, as Reported to the naïve patient. Pennsylvania Patient Safety Authority, July 2004 through June 2016 (n = 261) Similarly, rescue agents used to treat hypo- glycemia (e.g., dextrose, glucagon) were DRUG CLASS administered in 72.1% (n = 31 of 43) of 59 (22.6%) the wrong dose/overdosage errors involv- Opioid* ing insulin. Nearly one-fourth (23.3%, Insulin* 43 (16.5%) n = 10 of 43) of the reported wrong dose/overdosage errors involving insulin Anticoagulant* 24 (9.2%) resulted in a 10-fold overdose. Illegible handwriting, the use of error-prone abbre- Anticonvulsant 18 (6.9%) viations (e.g., “u” for units) and trailing Benzodiazepine 15 (5.7%) zeros, and confusing the product concen- tration (i.e., 100 units/mL) with the dose Antibiotic 12 (4.6%) were identified as contributing factors linked to insulin overdosage errors. Antihypertensive 12 (4.6%) Half (50.0%, n = 12 of 24) of the wrong Antineoplastic* 11 (4.2%) dose/overdosage events involving antico- agulants mentioned the use of a reversal Electrolyte 9 (3.4%) or rescue agent (e.g., vitamin K, prot- amine). Notable factors that contributed Antipsychotic 9 (3.4%) to anticoagulant overdosages included pre- 0 10 20 30 40 50 60 scribing the treatment dose instead of the MS16605 prophylaxis dose, wrong patient weight NUMBER OF REPORTS * High-alert medication (continued on page 85) Vol. 13, No. 3—September 2016 Pennsylvania Patient Safety Advisory Page 83 ©2016 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Table. Examples of Prescribing Errors and Likelihood of Being Intercepted by Current Versions of Computerized Prescriber Order Entry (CPOE) Systems with Clinical Decision Support (CDS) TYPE OF POSSIBLE CONTRIBUTING CLASSIFICATION EXAMPLE* EVENT FACTOR(S) Likely to be ED [emergency department] physician wrote for .5 mg Wrong dose/ Illegible handwriting intercepted with Dilaudid® [HYDROmorphone] IV. Handwriting looked overdosage CPOE and CDS like 5 mg. Due to patient’s size and severity of pain, ED nurse did not question order which she read as 5 mg. The patient arrested and was resuscitated and placed on a ventilator. The patient did not regain consciousness and expired. Physician ordered Imitrex® [sumatriptan] 6 mg. No Wrong route Incomplete order route or frequency documented. New graduate nurse gave Imitrex 6 mg IV. Patient experienced feeling of “being on fire,” elevated heart rate and diaphoresis. Patient with atrial fibrillation was ordered verapamil Wrong dosage Nomenclature issue— 360 mg po. It was given as immediate release. form drug name suffix/modifier Patient became hypotensive necessitating transfer to the ICU [intensive care unit]. Possibly intercepted Patient taking Effient® [prasugrel]. Post- Duplicate therapy Breakdown in medication with CPOE and CDS catheterization orders started Plavix® [clopidogrel]. reconciliation Both medications given and patient developed No active screening for thrombocytopenia. duplicate therapy Female patient seen in the ED for cellulitis Contraindicated No active screening of drug of the wrist and was prescribed Bactrim™ DS drug order against laboratory [sulfamethoxazole and trimethoprim] with a SCr values [serum creatinine] of 4.2 mg/dL. The drug should have been contraindicated based on the patient’s renal insufficiency. Patient admitted on Lexapro® [escitalopram] for Drug-drug No active screening for depression. During hospitalization, physician ordered interaction drug-drug interactions Zyvox® [linezolid] 600 mg every 12 hours. The Ability to bypass alert level drug interaction was not identified and the patient of major/highest severity developed signs of serotonin syndrome. Unlikely to be Physician was computer charting on one patient Wrong patient Multiple patient electronic intercepted with and switched to print-on-demand order sheet which records open at the same CPOE and CDS pulled the wrong patient name to order sheet. time Methadone 50 mg was ordered on the wrong Technology malfunction patient. Cardiac catheterization was delayed 24 hours. Patient’s medication list from home states she takes Wrong drug Breakdown in medication HumaLOG® 75/25 Mix™ [insulin lispro protamine reconciliation and insulin lispro (rDNA origin)], 60 units in the Nomenclature issue— evening and 75 units in the morning. Physician drug name modifier inadvertently ordered HumaLOG [insulin lispro (rDNA origin)]—not 75/25 mix resulting in symptomatic hypoglycemic requiring D50 [dextrose 50%] IV. Patient admitted for I&D [incision and drainage] of Dose omission Slip or memory lapse shoulder joint. Patient was not written for pre-op or post-op antibiotics. * The details of the Pennsylvania Patient Safety Reporting System event narratives in this article have been modified to preserve confidentiality. Page 84 Pennsylvania Patient Safety Advisory Vol. 13, No. 3—September 2016 ©2016 Pennsylvania Patient Safety Authority (continued from page 83) The patient experienced stomatitis, wheezing, and difficulty swallowing. pancytopenia, was intubated and IV [infusion] stopped. ED physician used to calculate dose, and inappropriate transferred to the ICU. The patient [came] to the room and initiated dose based on patients’ laboratory studies. coded and expired. treatment for anaphylaxis including Following are examples of reported errors IV Solu-Medrol® [methylPREDNISo- that resulted in wrong dose/overdosage:* Monitoring Error/Documented lone sodium succinate], IV Pepcid® Patient transferred to another Allergy [famotidine], and subcutaneous facility for shortness of breath. Patient Errors related to documented allergies EPINEPHrine. The patient was was on Lantus® [insulin glargine] accounted for 14.5% (n = 118 of 811) of placed on BiPap [bilevel positive insulin. When physician was reviewing reports. The medication classes most com- airway pressure] and symptoms/ the [previous] medication orders, the monly involved in documented allergy respiratory status improved. The ED Lantus order read Lantus 100 units/ events included antibiotics (40.7%, physician called the teaching service mL vial inject 16 units subcutaneously n = 48 of 118), opioids (22.0%, n = 26), residents and made them aware of at bedtime. Physician misinterpreted and nonsteroidal anti-inflammatory drugs the reaction. The patient was admit- this order to mean Lantus 100 units (NSAIDs; 8.5%, n = 10). Similar to find- ted to the ICU for close monitoring subcutaneously at bedtime and ordered ings published in a 2008 Pennsylvania of airway secondary to anaphylaxis. it as such. The patient’s blood sugar Patient Safety Advisory9, morphine topped Home medication list provided to the was 83 at 2100 on [day 1], so this the list of medications involved in docu- ED by the patient includes allergy to dose was not given and it was subse- mented allergy events (9.3%, n = 11). Ceftin® [cefuroxime]. quently decreased to 80 units. The Other commonly involved medications patient did receive the 80 units on include ketorolac (6.8%, n = 8), levo- Dose Omission Errors [day] 2 and the blood sugar dropped to The third most common event type FLOXacin (5.9%, n = 7), vancomycin 55 on [day 3]. The Lantus dose was reported was dose omissions (14.3%, (5.1%, n = 6), and ceFAZolin (4.2%, decreased again to 40 units on [day n = 5). The emergency department n = 116 of 811), which occurred when a 4] and was administered at bedtime. (ED) was the care area most frequently medication was not ordered or reordered At 0600 on [day 5] the patient had a cited (26.3%, n = 31) in documented despite being appropriate for the patient’s respiratory arrest and patient’s blood allergy events. Following are examples of underlying condition. Harm related sugar was 9. The patient was intu- reported prescribing errors that resulted to dose omission was most commonly bated, transferred to ICU [intensive in patients receiving a medication for reported with anticoagulants (18.1%, care unit], and placed on a ventilator. which they had a documented allergy: n = 21 of 116), anticonvulsants (17.2%, The patient was admitted to the n = 20), antibiotics (12.9%, n = 15), and ICU with sepsis and UTI [urinary Patient listed allergy [reaction] to vitamin K as paralysis. The physician insulin (10.3%, n = 12). Dose omissions tract infection]. The patient was on can occur at any high-risk transition point methotrexate as an outpatient [but] felt this was not a true allergy and ordered vitamin K to be administered in the patient’s admission (e.g., new the methotrexate was held during admission, transfer). Nearly 30% (27.6%, the ICU stay. The patient was later prior to a surgical procedure (INR [international normalized ratio] n = 32) of the dose omissions occurred transferred to the telemetry unit. [On when the patient’s maintenance medica- the eighth day of the admission], the 2.1). Patient suffered anaphylactic reaction, required intubation, pressor tion was omitted upon admission, 14.7% physician wrote for methotrexate (n = 17) occurred when a medication was 10 mg daily. The pharmacist entered support, and was transferred to ICU. omitted upon discharge, and 10.3% the dose and the patient received A patient [admitted] to the ED for (n = 12) occurred postoperatively. Nearly 7-days worth of the drug before the worsening cellulitis was evaluated 13% (12.9%, n = 15) of the dose omis- error was caught. The records from by the ED physician and given IV sions were caused when the provider failed the rehabilitation facility where the vancomycin. The patient was admit- to reorder a medication that had automati- patient came from were scanned over ted for IV antibiotic treatment by cally stopped. Following are examples of and they showed that the patient was teaching service and ordered cefepime 1 g IV, first dose now. An ED nurse reported dose omission errors: taking 5 mg on Sundays and 5 mg on Mondays (a total of 10 mg weekly). initiated this order prior to transfer to The patient had cardiac cath the inpatient unit. Cefepime started. [catheterization] with insertion of * The details of the PA-PSRS event narratives [Five minutes later], the patient drug eluting stents. On day one post- in this article have been modified to preserve procedure, the attending physician [developed] respiratory distress, confidentiality. Vol. 13, No. 3—September 2016 Pennsylvania Patient Safety Advisory Page 85 ©2016 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S told the physician assistant that the twice. The patient was intubated against unnecessary and prolonged drug patient was ready to go home and to protect airway. Admitted to the therapy, can also lead to unintended to resume home medications. The ICU which was initial plan for the discontinuation and dose omissions if physician assistant entered DCI patient anyway. The physician placed the prescriber fails to modify the default [discharge instructions]/medication an order for HYDROmorphone via duration of therapy within the electronic reconciliation and indicated that all CPOE on wrong patient’s record. order.14,15 The risk of placing orders in the home medications were to be resumed This medication was to be entered for wrong patient record exists in electronic but deleted all in-house medications. another patient. systems as it does in paper-based systems. Patient was discharged without orders Resident entered order into order In fact, an increased risk of placing or prescriptions for aspirin or Plavix® entry system on wrong patient. The orders on the wrong patient may be one [clopidogrel]. The patient was seen medication [rocuronium bromide] unintended consequence of CPOE. A in physician’s office [about a week was prepared, dispensed, and given 2013 analysis of PA-PSRS data found that later] with complaints of not feeling to the patient. the predominant type of wrong-patient well and having feelings of warmth prescribing errors involved a prescriber and cold. EKG [electrocardiogram] ordering a medication on the wrong DISCUSSION indicated a myocardial infarction chart.16 According to a study conducted with ST elevation. Repeat cardiac The use of technology to prevent and by Adelman et al., about 14 wrong patient cath [catheterization] identified occlu- detect medication errors has been increas- electronic orders were placed every day in sion of LAD [left anterior descending ing over the past decade. CPOE systems a large hospital system. These errors are coronary artery]. with CDS designed to assist prescribers sometimes due to juxtaposition, whereby with therapeutic decisions have been pro- the wrong patient may be selected from a A patient post CABG [coronary moted for their ability to reduce serious list of names, but are more often caused artery bypass grafting] with sternal medication errors by more than 50%.10,11 by interruptions and having more than wound infection underwent ster- A 2013 survey showed that nearly 80% one patient’s electronic record open.17 nectomy and placed on long term of US hospitals used a CPOE system, Wrong drug or strength selection from ceFAZolin. The patient developed a 58.6% increase from 2007.12,13 Of the a dropdown menu or picklist is another recurrent MSSA [methicillin-sus- hospitals with CPOE, 61.4% reported failure mode that may be introduced ceptible Staphylococcus aureus] concurrent CDS use.12 CPOE could avert with CPOE. An analysis of electronic bacteremia/sepsis, and it was discov- many of the contributing factors that lead prescribing systems in two hospitals found ered that antibiotics expired without to prescribing errors, including poorly that incorrect selection errors from a knowledge of the physician. The pa- handwritten prescriptions, improper ter- drop-down menu were the most frequent tient missed 3 doses/day for 10 days. minology, ambiguous orders, and omitted mechanism of CPOE system-related medi- Pharmacy policy automatically dis- information. A study conducted by Bobb cation errors.18 continues antibiotics after 10 days and colleagues assessed the potential unless order specifies otherwise. CDS systems provide various forms impact of CPOE and found that 64.4% and levels of alerts to indicate possible of prescribing errors were likely to be pre- Wrong Patient Errors vented with CPOE, including 43% of the issues with medication orders. However, The fourth most common (4.4%, n = 36 when these alerts are not analyzed and potentially harmful errors.3 In the present of 811) type of reported prescribing errors prioritized, the excessive number of alerts analysis, CPOE with properly imple- were wrong patient errors. The majority displayed may lead to alert fatigue or may mented and optimized CDS would likely (55.6%, n = 20 of 36) of these reports prompt hospitals to turn off alerts, or a be able to intercept and possibly prevent did not provide enough information to subset of alerts, altogether. Alert fatigue the drug-allergy interaction errors and ascertain the type of order (e.g., verbal, may cause prescribers to override many possibly intercept and prevent the wrong handwritten, CPOE). Of the remaining of the safety features afforded by CPOE dose/overdosage errors. reports, 75% (n = 12 of 16) of the orders and CDS, including alerts of high severity were placed via CPOE, 18.8% (n = 3) CPOE and electronic health record when they are buried among irrelevant were handwritten, and 6.3% (n = 1) were (EHR) systems currently in place in or less significant alerts. A 2015 study communicated verbally. Following are healthcare facilities are probably unable of PA-PSRS data found that CPOE was examples of reported wrong patient errors: to catch and prevent errors of omission the second most common technology occurring during the prescribing phase. involved in medication error event reports The patient became somnolent. Automated stopping (auto-stop) values, related to overrides.19 Narcan® [naloxone] administered which are used to help safeguard patients Page 86 Pennsylvania Patient Safety Advisory Vol. 13, No. 3—September 2016 ©2016 Pennsylvania Patient Safety Authority Understanding vulnerabilities in CPOE RISK REDUCTION STRATEGIES Drug Information and CDS systems is key to developing While prescribing errors may be inter- —— Develop an expedited admission effective preventive measures. A 2010 cepted during subsequent phases of the reconciliation process for specific analysis of 62 US hospitals’ CPOE sys- medication use process, these errors high-alert medications such as tems found that nearly 50% of prescribing can reach patients and cause serious insulin, anti-arrhythmic agents, and errors that would result in patient fatal- harm, including death. It is important other medications that may need ity were unable to be detected.20 More that stakeholders, including healthcare to be given to a patient before the recently, researchers tested the vulnerabil- generally-accepted, 24-hour medica- organizations and health information ity of thirteen CPOE systems to erroneous tion reconciliation time limit.26 technology vendors, continue to develop, medication orders and found that nearly implement, and refine CPOE and CDS —— Each time a patient moves from one 80% of the unsafe orders could be placed. systems to better support prescribers and care setting to another, review previ- Over half of the orders were easily entered make it easier to select the correct action. ous medication orders alongside new or entered with minor workarounds and Consider the strategies described below, orders and plans for care, and resolve only 26.6% of the unsafe orders gener- which are based on a review of current lit- any discrepancies.27 ated warnings.21 Evidence of high rates of erature, events reported to the Authority, —— Establish and enforce institutional, adverse drug events in a highly computer- ized hospital further illustrates the need and observations from the Institute for therapy-specific dose limits. Such to ensure that electronic systems are oper- Safe Medication Practices (ISMP). limits could include the maximum ating efficiently before replacing manual amount for a single dose, cumulative safety checks.22 To ensure CPOE systems Patient Information dose for a 24-hour period, and for are performing well and as expected, it is —— Ensure that current and complete each component of a combination important for organizations to regularly allergy information, including product.28 monitor, test, and enhance these systems. descriptions of the reactions, is read- —— If your organization has an auto- The Computerized Prescriber Order Entry ily available to all prescribers when matic stop policy, evaluate your (CPOE) System Evaluation Toolkit was devel- they are ordering medications.9 organization’s list of drugs and the oped as a supplement to this Advisory to —— Establish a forcing function to make associated indications governed by help organizations test their CPOE and the allergy, as well as a description of this policy to determine whether CDS systems, to better understand their the reaction to the allergen, manda- a valid need exists for the drugs to ability to detect unsafe orders and their tory entries into the organization’s remain on the list. 14 management of high severity alerts. CPOE system.9 The Toolkit is available http://patient Communication of Drug safetyauthority.org/EducationalTools/ —— Encourage prescribers to verify the patient’s identity using two identifi- Information PatientSafetyTools/Pages/home.aspx. ers when prescribing drug therapy.23 —— Limit the use of verbal orders to —— Standardize the baseline patient emergency situations.16 Limitations information, including weight in —— Encourage prescribers to avoid using In-depth analysis by the Authority of kilograms and laboratory values (e.g., error-prone abbreviations (e.g., “u” Serious Events resulting from medica- serum creatinine), needed to order for units) in all written and elec- tion prescribing errors is limited by the medications that require adjustment tronic communication.29 information reported through PA-PSRS, based upon patient characteristics including the event descriptions. As Standardization (e.g., anticoagulants), and have a with all reporting systems, the type and standard process in place to update —— Use carefully developed standard number of reports collected depend on this information in the EHR.24 order sets to minimize incorrect or the degree to which facility reporting is —— Implement functionality to improve incomplete prescribing, standardize accurate and complete. Information about the capture and accuracy of all patient care, and ensure clarity when underlying patient conditions, which comorbid conditions in a structured communicating medication orders.30 may have impacted dose calculations for individual patients, such as opioid diagnosis/problem list field in the —— In order sets that include opioid tolerance, was not consistently available. patient’s EHR, and to link this infor- drugs, guide prescribers to an appro- Information regarding the adoption and mation to the order entry system, to priate opioid dose based on patient use of CPOE and CDS by the reporting promote appropriate screening when age and opioid tolerance by provid- facilities was also not available. new drugs are prescribed.25 ing default doses for three types Vol. 13, No. 3—September 2016 Pennsylvania Patient Safety Advisory Page 87 ©2016 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S of patients: (1) most patients, (2) Evaluation Toolkit, available at http:// —— Improve the positive predictive patients older than 64 years or with patientsafetyauthority.org/Education value of alerts (e.g., the number sleep apnea, and (3) opioid-tolerant alTools/PatientSafetyTools/Pages/ of true positive alerts compared patients.31 home.aspx, to test the facility's CPOE with all positive alerts), and adjust system to see whether potentially fatal the presentation of the alerts (e.g., Environmental Factors errors—such as an order for daily oral interruptive versus noninterruptive) —— Consider designing CPOE systems methotrexate—are detected. according to the level of severity.19 to allow prescribers to select the —— Encourage prescribers to report —— Develop a mechanism to identify patient name from a list of patients CPOE-related errors including incor- and remove alerts that provide little assigned to him/her instead of a rect or incomplete CDS information or no clinical value, which may con- much larger list of patients.23 and develop a standard process tribute to alert fatigue.19 —— Limit distractions during critical to make timely safety and quality —— Examine the systems in place for tasks such as medication selection.32 enhancements. notifying prescribers about automatic —— Enhance the font size and readability —— Measure the use of trigger drugs used stop orders, the timing of the notifi- of patient names on EHR screens.23 to reverse the effects of medication cation, and the process for review.14 overdoses (e.g., naloxone, vitamin K, Staff Competency and Education glucagon, dextrose 50%) to increase CONCLUSION —— Provide prescribers with education detection of preventable adverse Of the serious prescribing errors reported on medication allergies. Educational drug events (ADEs) that may have to the Authority since the inception of efforts need to focus on screening been caused by medication errors.34 the program in 2004, the most common patients for potential allergic or (Visit the Authority’s website at error types reported were: wrong dose/ other adverse reactions, recognizing http://patientsafetyauthority.org/ overdosage, prescribing a medication to an allergic reaction, and treating seri- EducationalTools/PatientSafety which a patient has a documented allergy, ous reactions.9 Tools/opioids/Pages/ADEWork dose omission, and prescribing a medica- —— After CPOE and CDS implemen- sheet.aspx to view or download a tion for the wrong patient. Well designed tation, prioritize the most critical sample tool that can be used to iden- and implemented CPOE and CDS sys- elements to plan for annual or semi- tify and monitor actual or potential tems are likely to intercept and possibly annual retraining and competency problems with the use of insulin, prevent nearly one-quarter of these errors; verification.33 opioids, and anticoagulants.) however, evidence shows that poorly —— Assess staff competency related to —— Measure the use of trigger drugs designed and implemented CPOE and the safe use of CPOE, CDS, and used to treat allergic reactions (e.g., CDS systems may introduce other types of overrides, and provide education diphenhyDRAMINE, methyl- errors. Opportunities exist for increasing when indicated.19 PREDNISolone, EPINEPHrine) to the benefits that can be realized by CPOE increase detection of preventable with CDS. However, prescribing is just Quality Processes and Risk ADEs and determine whether there one phase of the medication use process. Management are other instances of patients with Implementing layers of risk-reduction strat- documented allergies erroneously egies across all phases of the medication —— Consider using the Computerized receiving medications.9 use process may help prevent prescribing Prescriber Order Entry (CPOE) System errors from reaching the patient. NOTES 1. Bates DW, Cullen DJ, Laird N, et al. Inci- 3. Bobb A, Gleason K, Husch M, et al. The 5. Lesar TS, Briceland LL, Delcoure K, dence of adverse drug events and potential epidemiology of prescribing errors: the et al. Medication prescribing errors in adverse drug events. Implications for pre- potential impact of computerized pre- a teaching hospital. JAMA 1990 May vention. ADE Prevention Study Group. scriber order entry. Arch Intern Med 2004 2;263(17):2329-34. JAMA 1995 Jul 5;274(1):29-34. Apr 12;164(7):785-92. 6. National Coordinating Council for Medi- 2. Leape LL, Bates DW, Cullen DJ, et al. Sys- 4. Lesar TS, Briceland L, Stein DS. Factors cation Error Reporting and Prevention. tems analysis of adverse drug events. ADE related to errors in medication prescrib- NCC MERP index for categorizing medi- Prevention Study Group. JAMA 1995 Jul ing. JAMA 1997 Jan 22-29;277(4):312-17. cation errors [online]. 2001 Feb [cited 5;274(1):35-43. 2016 Apr 7]. http://www.nccmerp.org/ types-medication-errors Page 88 Pennsylvania Patient Safety Advisory Vol. 13, No. 3—September 2016 ©2016 Pennsylvania Patient Safety Authority 7. Kuperman GJ, Bobb A, Payne TH, et al. 17. Adelman JS, Kalkut GE, Schechter CB, 27. Institute for Safe Medication Practices. Medication-related clinical decision sup- et al. Understanding and preventing Building a case for medication reconcilia- port in computerized provider order entry wrong-patient electronic orders: a ran- tion. ISMP Med Saf Alert Acute Care 2005 systems: a review. J Am Med Inform Assoc domized controlled trial. J Am Med Inform Apr 21;10(8):1-2. Also available at http:// 2007 Jan-Feb;14(1):29-40 [cited 2016 Apr Assoc 2013 Mar-Apr;20(2):305-10. www.ismp.org/newsletters/acutecare/ 7]. Also available at http://jamia.oxford- 18. Westbrook JI, Baysari MT, Li L, et al. articles/20050421.asp journals.org/content/14/1/29 The safety of electronic prescribing: 28. Cohen MR. Preventing prescribing errors. 8. Institute for Safe Medication Practices. manifestations, mechanisms, and Chapter 9. In: Cohen MR. Medication ISMP list of high-alert medications in rates of system-related errors associ- errors, 2nd ed. Washington (DC): Ameri- acute care settings [online]. 2014 [cited ated with two commercial systems in can Pharmacists Association; 2007. 2016 Apr 7]. http://www.ismp.org/Tools/ hospitals. J Am Med Inform Assoc 2013 29. Pennsylvania Patient Safety Authority. institutionalhighAlert.asp Nov-Dec;20(6):1159-67. Abbreviations: a shortcut to medication 9. Medication errors associated with docu- 19. Grissinger M. Medication errors involv- errors [online]. Pa Patient Saf Advis 2005 mented allergies [online]. Pa Patient Saf ing overrides of healthcare technology Mar [cited 2016 May 16]. http://patient Advis 2008 Sep [cited 2016 Apr 7]. http:// [online]. Pa Patient Saf Advis 2015 Dec safetyauthority.org/ADVISORIES/ patientsafetyauthority.org/ADVISO [cited 2016 Apr 7]. http://patient AdvisoryLibrary/2005/Mar2(1)/ RIES/AdvisoryLibrary/2008/Sep5(3)/ safetyauthority.org/ADVISORIES/ Pages/19.aspx Pages/75.aspx AdvisoryLibrary/2015/Dec;12(4)/ 30. Institute for Safe Medication Practices. 10. Bates DW, Leape LL, Cullen DJ, et al. Pages/141.aspx ISMP develops guidelines for standard Effect of computerized physician order entry and a team intervention on preven- 20. Metzger J, Welebob E, Bates DW, et al. order sets. ISMP Med Saf Alert Acute Care tion of serious medication errors. JAMA Mixed results in the safety performance 2010 Mar 11;15(5):1-4. Also available at 1998 Oct 21;280(15):1311-16. of computerized physician order entry. http://www.ismp.org/newsletters/ Health Aff 2010 Apr;29(4):655-63. acutecare/articles/20100311.asp 11. Bates DW, Teich JM, Lee J, et al. The impact of computerized physician 21. Schiff GD, Amato MG, Eguale T, et al. 31. Institute for Safe Medication Practices. order entry on medication error pre- Computerised physician order entry- Beware of basal opioid infusions with vention. J Am Med Inform Assoc 1999 related medication errors: analysis of PCA therapy. ISMP Med Saf Alert Acute Jul-Aug;6(4):313-21. reported errors and vulnerability testing Care 2009 Mar 12;14(5):1-3. Also avail- 12. Fox BI, Pedersen CA, Gumpper KF. of current systems. BMJ Qual Saf 2015 able at http://www.ismp.org/newsletters/ ASHP national survey on informatics: Apr;24(4):264-71. acutecare/articles/20090312.asp assessment of the adoption and use of 22. Nebeker JR, Hoffman JM, Weir CR, et 32. Paparella SF. Accurate patient identifi- pharmacy informatics in U.S. hospi- al. High rates of adverse drug events in a cation in the emergency department: tals-2013. Am J Health Syst Pharm 2015 highly computerized hospital. Arch Intern meeting the safety challenges. J Emerg Nurs Apr 15;72(8):636-55. Med 2005 May 23;165(10):1111-16. 2012 Jul;38(4):364-7. 13. Pedersen CA, Gumpper KF. ASHP 23. Institute for Safe Medication Practices. 33. Institute for Safe Medication Practices. national survey on informatics: assessment Oops, sorry, wrong patient! A patient Developing productive partnerships with of the adoption and use of pharmacy infor- verification process is needed everywhere technology and device vendors to improve matics in U.S. hospitals-2007. Am J Health not just at the bedside. ISMP Med Saf Alert staff training. ISMP Med Saf Alert Acute Syst Pharm 2008 Dec 1;65(23):2244-64. Acute Care 2011 Mar 10;16(5):1-4. Also Care 2013 Aug 22;18(17):1-3. Also avail- 14. Institute for Safe Medication Practices. available at http://www.ismp.org/news able at http://www.ismp.org/Newsletters/ Let’s put a stop to problem-prone auto- letters/acutecare/articles/20110310.asp acutecare/showarticle.aspx?id=57 matic stop order policies. ISMP Med Saf 24. Andreica I, Grissinger M. Oral anticoagu- 34. Institute for Safe Medication Practices. Alert Acute Care 2000 Aug 8;5(16):1. Also lants: a review of common errors and risk Measuring up to medication safety. available at http://www.ismp.org/news reduction strategies [online]. Pa Patient Saf ISMP Med Saf Alert Acute Care 2005 Mar letters/acutecare/articles/20000809_2.asp Advis 2015 Jun [cited 2016 Apr 7]. http:// 10;10(5):1-2. Also available at http:// 15. Sparnon E. Spotlight on electronic health patientsafetyauthority.org/ADVISO www.ismp.org/newsletters/acutecare/ record errors: errors related to the use of RIES/AdvisoryLibrary/2015/Jun;12(2)/ articles/20050310.asp default values [online]. Pa Patient Saf Advis Pages/54.aspx 2013 Sept [cited 2016 Apr 7]. http:// 25. Institute for Safe Medication Practices. patientsafetyauthority.org/ADVISO The absence of a drug-disease interaction RIES/AdvisoryLibrary/2013/Sep;10(3)/ alert leads to a child’s death. ISMP Med Pages/92.aspx Saf Alert Acute Care 2015 May 21;20(10): 16. Yang A, Grissinger M. Wrong-patient 1-4. Also available at http://www.ismp. medication errors: an analysis of event org/newsletters/acutecare/showarticle. reports in Pennsylvania and strategies for aspx?id=109 prevention [online]. Pa Patient Saf Advis 26. Gao T, Gaunt M. Breakdowns in the med- 2013 Jun [cited 2016 Apr 7]. http:// patientsafetyauthority.org/ADVISO- ication reconciliation process [online]. RIES/AdvisoryLibrary/2013/Jun;10(2)/ Pa Patient Saf Advis 2013 [cited 2016 Apr Pages/41.aspx 7]. http://patientsafetyauthority.org/ ADVISORIES/AdvisoryLibrary/2013/ Dec;10(4)/Pages/125.aspx Vol. 13, No. 3—September 2016 Pennsylvania Patient Safety Advisory Page 89 ©2016 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S LEARNING OBJECTIVES SELF-ASSESSMENT QUESTIONS —— Identify the most common prescrib- 1. Which of the following prescribing error event types was most frequently reported ing error event types associated to the Authority as a Serious Event? with Serious Events, as reported a. Wrong patient to the Pennsylvania Patient Safety b. Wrong rate (IV) Authority. c. Wrong duration —— Predict what types of prescrib- d. Wrong dose/overdosage ing errors are likely, possible, and e. Wrong dose/under dosage unlikely to be intercepted by comput- 2. Which of the following type of event or contributing factor is NOT likely to be pre- erized prescriber order entry (CPOE) vented or intercepted by CPOE with properly implemented and optimized CDS? with clinical decision support (CDS). a. Incomplete orders —— Identify and assess risk reduction b. Illegible handwriting strategies that can be implemented to help prevent prescribing errors. c. Drug-allergy interaction d. Wrong dose formulation e. Adverse drug reaction 3. Which of the following prescribing errors is NOT likely to be intercepted by CPOE with properly implemented and optimized CDS? a. An emergency department physician ordered .5 mg HYDROmorphone IV; however, the handwritten order looked like 5 mg. b. A physician ordered sumatriptan 6 mg but did not include route or frequency. A new graduate nurse gave sumatriptan 6 mg IV. c. A physician was documenting care in one patient’s electronic medical record. The physician then switched to print-on-demand order sheet, which pulled the wrong patient name to order sheet. Methadone 50 mg was ordered on the wrong patient. d. Verapamil 360 mg daily by mouth was ordered for a patient with atrial fibrilla- tion. The pharmacy dispensed the immediate-release formulation, which was administered to the patient. e. A patient was taking prasugrel. The post-catheterization orders stated to administer clopidogrel. Both medications were given and the patient devel- oped thrombocytopenia. 4. Which of the following is NOT a quality improvement strategy that can be used to optimize CDS for CPOE? a. Improve the positive predictive value of alerts, and adjust their presentation so interruptive alerts fire for alerts of low severity. b. After CPOE and CDS implementation, prioritize the most critical informa- tion about CPOE and CDS to plan for annual or semiannual retraining and competency verification. c. Develop a mechanism to identify and remove alerts that provide little or no clinical value. d. Provide a mechanism to enable prescribers to report CPOE-related errors including incorrect or incomplete CDS information, and develop a standard process to make timely safety and quality enhancements. e. Assess staff competency related to the safe use of CPOE, CDS, and overrides, and provide education when indicated. Page 90 Pennsylvania Patient Safety Advisory Vol. 13, No. 3—September 2016 ©2016 Pennsylvania Patient Safety Authority SELF-ASSESSMENT QUESTIONS (CONTINUED) Question 5 refers to the following case: The patient was admitted to the intensive care unit (ICU) with sepsis and a urinary tract infection. The patient was on methotrexate as an outpatient but the methotrex- ate was held during the ICU stay. The patient was later transferred to the telemetry unit. On the eighth day of the admission, the physician wrote for methotrexate 10 mg daily. The pharmacist entered the dose and the patient received 7 days’ worth of the drug before the error was caught. The records from the rehabilitation facility where the patient came from were scanned over and they showed that the patient was taking methotrexate 5 mg on Sunday and methotrexate 5 mg on Monday for a total of 10 mg weekly. The patient experienced stomatitis, pancytopenia, was intubated and transferred to the ICU. The patient coded and expired. 5. Which of the following risk-reduction strategies would NOT help prevent this pre- scribing error? a. Proactive testing of the facility’s CPOE system to see whether potentially fatal errors (e.g., an order for daily oral methotrexate for non-oncologic indications) are detected. b. Implement functionality to improve the capture and accuracy of all comorbid conditions in a structured diagnosis/problem list field in the electronic health record, and link this information to the order entry system, to promote appro- priate screening when new drugs are prescribed. c. Establish and enforce institutional, therapy-specific dose limits. d. Review previous medication orders alongside new orders and plans for care, and resolve any discrepancies each time a patient moves from one care setting to another. e. Measure the facility’s use of trigger drugs (e.g., naloxone, vitamin K, gluca- gon, dextrose 50%) to reverse the effects of medication overdoses to increase detection of adverse drug events that may have been caused by preventable medication errors, and track performance over time. Vol. 13, No. 3—September 2016 Pennsylvania Patient Safety Advisory Page 91 ©2016 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 13, No. 3—September 2016. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2016 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (Mcare) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s website at http://www.patientsafetyauthority.org. An Independent Agency of the Commonwealth of Pennsylvania ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 50 years, ECRI Institute marries experience and indepen- dence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions. Scan this code with your mobile device’s QR reader to subscribe to receive the Advisory for free.