February 1, 2012 — Implementation of 2 commercial e-prescribing systems significantly reduced prescribing errors, including serious errors, at 2 Australian hospitals, according to results from a study published online January 31 in PloS Medicine.
"Considerable investments are being made in commercial electronic prescribing systems (e-prescribing) in many countries," write lead author Professor Johanna Westbrook, PhD, from the University of New South Wales, Sydney, Australia, and colleagues.
However, they note, "Few studies have measured or evaluated their effectiveness at reducing prescribing error rates, and interactions between system design and errors are not well understood, despite increasing concerns regarding new errors associated with system use."
These researchers evaluated the effect of 2 commercially available e-prescribing systems on reducing prescribing errors and assessed their propensity for creating new types of errors.
The authors looked for procedural and clinical errors in medication charts at 2 Sydney teaching hospitals, both before and after the introduction of e-prescribing systems. Procedural errors included unclear, incomplete, or illegal prescribing orders, and clinical errors included prescribing an incorrect drug or incorrect dose.
At hospital A, the Cerner Millennium e-prescribing system was introduced on a single geriatric ward. Three other wards (a renal/vascular ward, a respiratory ward, and another geriatric ward) served as controls.
At hospital B, the researchers compared error rates in 2 wards (psychiatry and cardiology) both before and after the iSoft MedChart system was introduced.
"The introduction of an e-prescribing system was associated with a substantial reduction in error rates in the three intervention wards; error rates on the control wards did not change significantly during the study," the researchers write.
In hospital A, error rates declined from 6.25 (95% confidence interval [CI], 5.23 - 7.28) to 2.12 (95% CI, 1.71 - 2.54; P < .0001) per admission after the e-prescribing system was put into use, the researchers say.
Similar results were seen in hospital B, with error rates falling from 3.62 (95% CI, 3.30 - 3.93) to 1.46 (95% CI, 1.20 - 1.73; P < .0001) per admission.
The researchers attributed the decline in error rates primarily to reductions in procedural errors; clinical errors showed only modest reductions.
However, the authors stress that the introduction of e-prescribing had a significant effect on serious errors, defined as errors that would be likely to lead to death. Rates for serious errors fell across all the intervention wards, from 0.25 per admission to 0.14 per admission (P = .0002), which is a 44% decline.
In contrast, serious error rates in control wards declined by only 17% during the study.
System-related errors (eg, choosing an incorrect drug from a drop-down menu) were responsible for about 35% of the errors seen in the intervention wards after the e-prescribing systems were put into place, the authors write.
That high rate of system-related errors is worrisome, the authors concede, but they say such errors could be corrected by tweaking the systems and improving user training.
The authors point out several limitations of the study, including lack of control wards in hospital B and the inability to randomize hospital wards to the intervention.
Commenting on the study, Lyman Dennis, MBA, PhD, who heads El Dorado Health Consulting in Fairfield, California, told Medscape Medical News, "This study is important because it verifies that electronic systems do improve care, both in terms of improving the accuracy of procedural steps as well as clinical execution. But it also clearly shows that the factor of human error is not removed simply by utilizing these information systems."
Dr. Dennis says another point highlighted by the findings is that hospitals need to have implementation of e-prescribing systems imbedded in some sort of quality improvement process. "You shouldn't have the expectation that when you've finished implementing the system everything is immediately going to proceed smoothly," he said.
Most e-prescribing systems offer a multitude of choices when navigating various screens, and Dr. Dennis points out that although having lots of choices creates flexibility, it can also cause errors. "When many options are offered, making the proper selection can involve a rather fine mouse click, or a fine touch of the screen, and it can be easy to make an incorrect choice," he said.
However, on balance, Dr. Dennis says, e-prescribing makes sense for hospitals. "Though, as we've seen in this study, such systems are associated with an increase in system-related errors, the reduction in serious procedural and clinical errors more than makes up for that," he said.
The research was supported by grants from the National Health and Medical Research Council. One of the study authors has, in the past, had shares and acted as a consultant to give general advice on incident reporting to Patient Safety International. He also was a board member of Patient Safety International, which at that stage was, but is no longer, a subsidiary of the not-for-profit research organization the Australian Patient Safety Foundation, of which he has been and is president. Another coauthor spoke on "Electronic Medication Management and the Hospital Pharmacist" at the Cerner Regional User Group meeting in 2010 at the request of her employer. She personally received no honorarium or fees from this speaking engagement. The other authors and Dr. Dennis have disclosed no relevant financial relationships.
PloS Med. Published online January 31, 2012. Article
"Considerable investments are being made in commercial electronic prescribing systems (e-prescribing) in many countries," write lead author Professor Johanna Westbrook, PhD, from the University of New South Wales, Sydney, Australia, and colleagues.
However, they note, "Few studies have measured or evaluated their effectiveness at reducing prescribing error rates, and interactions between system design and errors are not well understood, despite increasing concerns regarding new errors associated with system use."
These researchers evaluated the effect of 2 commercially available e-prescribing systems on reducing prescribing errors and assessed their propensity for creating new types of errors.
The authors looked for procedural and clinical errors in medication charts at 2 Sydney teaching hospitals, both before and after the introduction of e-prescribing systems. Procedural errors included unclear, incomplete, or illegal prescribing orders, and clinical errors included prescribing an incorrect drug or incorrect dose.
At hospital A, the Cerner Millennium e-prescribing system was introduced on a single geriatric ward. Three other wards (a renal/vascular ward, a respiratory ward, and another geriatric ward) served as controls.
At hospital B, the researchers compared error rates in 2 wards (psychiatry and cardiology) both before and after the iSoft MedChart system was introduced.
"The introduction of an e-prescribing system was associated with a substantial reduction in error rates in the three intervention wards; error rates on the control wards did not change significantly during the study," the researchers write.
In hospital A, error rates declined from 6.25 (95% confidence interval [CI], 5.23 - 7.28) to 2.12 (95% CI, 1.71 - 2.54; P < .0001) per admission after the e-prescribing system was put into use, the researchers say.
Similar results were seen in hospital B, with error rates falling from 3.62 (95% CI, 3.30 - 3.93) to 1.46 (95% CI, 1.20 - 1.73; P < .0001) per admission.
The researchers attributed the decline in error rates primarily to reductions in procedural errors; clinical errors showed only modest reductions.
However, the authors stress that the introduction of e-prescribing had a significant effect on serious errors, defined as errors that would be likely to lead to death. Rates for serious errors fell across all the intervention wards, from 0.25 per admission to 0.14 per admission (P = .0002), which is a 44% decline.
In contrast, serious error rates in control wards declined by only 17% during the study.
System-related errors (eg, choosing an incorrect drug from a drop-down menu) were responsible for about 35% of the errors seen in the intervention wards after the e-prescribing systems were put into place, the authors write.
That high rate of system-related errors is worrisome, the authors concede, but they say such errors could be corrected by tweaking the systems and improving user training.
The authors point out several limitations of the study, including lack of control wards in hospital B and the inability to randomize hospital wards to the intervention.
Commenting on the study, Lyman Dennis, MBA, PhD, who heads El Dorado Health Consulting in Fairfield, California, told Medscape Medical News, "This study is important because it verifies that electronic systems do improve care, both in terms of improving the accuracy of procedural steps as well as clinical execution. But it also clearly shows that the factor of human error is not removed simply by utilizing these information systems."
Dr. Dennis says another point highlighted by the findings is that hospitals need to have implementation of e-prescribing systems imbedded in some sort of quality improvement process. "You shouldn't have the expectation that when you've finished implementing the system everything is immediately going to proceed smoothly," he said.
Most e-prescribing systems offer a multitude of choices when navigating various screens, and Dr. Dennis points out that although having lots of choices creates flexibility, it can also cause errors. "When many options are offered, making the proper selection can involve a rather fine mouse click, or a fine touch of the screen, and it can be easy to make an incorrect choice," he said.
However, on balance, Dr. Dennis says, e-prescribing makes sense for hospitals. "Though, as we've seen in this study, such systems are associated with an increase in system-related errors, the reduction in serious procedural and clinical errors more than makes up for that," he said.
The research was supported by grants from the National Health and Medical Research Council. One of the study authors has, in the past, had shares and acted as a consultant to give general advice on incident reporting to Patient Safety International. He also was a board member of Patient Safety International, which at that stage was, but is no longer, a subsidiary of the not-for-profit research organization the Australian Patient Safety Foundation, of which he has been and is president. Another coauthor spoke on "Electronic Medication Management and the Hospital Pharmacist" at the Cerner Regional User Group meeting in 2010 at the request of her employer. She personally received no honorarium or fees from this speaking engagement. The other authors and Dr. Dennis have disclosed no relevant financial relationships.
PloS Med. Published online January 31, 2012. Article
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