Electronic prescribing within an electronic health record reduces ambulatory prescribing errors

Barriers to electronic prescribing of controlled substance, especially opioids

OBJECTIVE

Electronic prescriptions are now the standard of practice for all discharge and outpatient prescriptions. The intention is to increase patient safety, provide a more complete medication record for patients, lessen the burden on prescribers, and shorten the time it takes for medication orders to reach the pharmacy.

DESIGN

This cross-sectional questionnaire survey study was conducted between January and August 2022 in three areas of a large urban safety net hospital.

SETTING

A large single academic medical center.

PARTICIPANTS

Emergency department, inpatient clinicians, and procedural areas. The subjects of the study were trainees, attending physicians, and advance practice providers (APPs) Interventions: Data were collected from the participants using a self-reported questionnaire, including sociodemographic characteristics, ease of use, reliability, and preference. Additionally, the perception of the strengths and limitations associated with electronic prescribing (e-prescribing) were analyzed.

MAIN OUTCOME MEASURE

The purpose of this study was to evaluate the barriers to e-prescribing of opioids.

RESULTS

A total of 121 prescribers completed the survey. The majority trusted that e-prescribing were transmitted successfully (62 percent), saved time (78 percent), and did not interrupt their workflow (78 percent). However, many prescribers indicated that additional improvements are needed, such as updating the patient's preferred pharmacy in the electronic medical record during each visit (52 percent) and having a 24-hour pharmacy readily available (66 percent).

CONCLUSION

Prescribers value the ease of use of e-prescribing and how time efficient the process can be. Nevertheless, there is a need to improve the system's service, design, and usefulness.

E-prescribing and medication safety in community settings: A rapid scoping review

Background

Medication prescribing is essential for the treatment, curing, maintenance, and/or prevention of an illness and disease, however, medication errors remain common. Common errors including prescribing and administration, pose significant risk to patients. Electronic prescribing (e-prescribing) is one intervention used to enhance the safety and quality of prescribing by decreasing medication errors and reducing harm. E-prescribing in community-based settings has not been extensively examined.

Objective

To map and characterize the current evidence on e-prescribing and medication safety in community pharmacy settings.

Methods

We conducted a rapid scoping review of quantitative, qualitative, and mixed methods studies reporting on e-prescribing and medication safety. MEDLINE All (OVID), Embase (Elsevier), CINAHL Full Text (EBSCOHost), and Scopus (Elsevier) databases were searched December 2022 using keywords and MeSH terms related to e-prescribing, medication safety, efficiency, and uptake. Articles were imported to Covidence and screened by two reviewers. Data were extracted by a single reviewer and verified by a second reviewer using a standardized data extraction form. Findings are reported in accordance with JBI Manual for Evidence Synthesis following thematic analysis to narratively describe results.

Results

Thirty-five studies were included in this review. Most studies were quantitative (n = 22), non-experimental study designs (n = 16) and were conducted in the United States (n = 18). Half of included studies reported physicians as the prescriber (n = 18), while the remaining reported a mix of nurse practitioners, pharmacists, and physician assistants (n = 6). Studies reported on types of errors, including prescription errors (n = 20), medication safety errors (n = 9), dispensing errors (n = 2), and administration errors (n = 1). Few studies examined patient health outcomes, such as adverse drug events (n = 5).

Conclusions

Findings indicate that most research is descriptive in nature and focused primarily on rates of prescription errors. Further research, such as experimental, implementation, and evaluation mixed-methods research, is needed to investigate the effects of e-prescribing on reducing error rates and improving patient and health system outcomes.

The Effects of the Use of Patient-Accessible Electronic Health Record Portals on Cancer Survivors’ Health Outcomes: Cross-sectional Survey Study

Background

In the past decade, patient-accessible electronic health record (PAEHR) systems have emerged as an important tool for health management both at the hospital level and individual level. However, little is known about the effects of PAEHR portals on the survivorship of patients with chronic health conditions (eg, cancer).

Objective

This study aims to investigate the effects of the use of PAEHR portals on cancer survivors’ health outcomes and to examine the mediation pathways through patient-centered communication (PCC) and health self-efficacy.

Methods

Data for this study were derived from the Health Information National Trends Survey (HINTS 5, Cycle 4) collected from February 2020 to June 2020. This study only involved respondents who reported having been diagnosed with cancer (N=626). Descriptive analyses were performed, and the mediation models were tested using Model 6 from the SPSS macro PROCESS. Statistically significant relationships among PAEHR portal use, PCC, health self-efficacy, and physical and psychological health were examined using bootstrapping procedures. In this study, we referred to the regression coefficients generated by min-max normalization as percentage coefficients (bp). The 95% bootstrapped CIs were used with 10,000 resamplings.

Results

No positive direct associations between PAEHR portal use and cancer survivors’ health outcomes were found. The results supported the indirect relationship between PAEHR portal use and cancer survivors’ psychological health via (1) PCC (bp=0.029; β=.023, 95% CI .009-.054), and (2) PCC and health self-efficacy in sequence (bp=0.006; β=.005, 95% CI .002-.014). Besides, the indirect association between PAEHR portal use and cancer survivors’ physical health (bp=0.006; β=.004, 95% CI .002-.018) via sequential mediators of PCC and health self-efficacy was also statistically acknowledged.

Conclusions

This study offers empirical evidence about the significant role of PAEHR portals in delivering PCC, improving health self-efficacy, and ultimately contributing to cancer survivors’ physical and psychological health.

Ambulatory Medication Safety in Primary Care: A Systematic Review

PURPOSE

To review the literature on medication safety in primary care in the electronic health record era.

METHODS

Included studies measured rates and outcomes of medication safety in patients whose prescriptions were written in primary care clinics with electronic prescribing. Four investigators independently reviewed titles and analyzed abstracts with dual-reviewer review for eligibility, characteristics, and risk of bias.

RESULTS

Of 1464 articles identified, 56 met the inclusion criteria. Forty-three studies were noninterventional and 13 included an intervention. The majority of the studies (30) used their own definition of error. The most common outcomes were potentially inappropriate prescribing/medications (PIPs), adverse drug events (ADEs), and potential prescribing omissions (PPOs). Most of the studies only included high-risk subpopulations (39), usually older adults taking > 4 medications. The rate of PIPs varied widely (0.19% to 98.2%). The rate of ADEs was lower (0.47% to 14.7%). There was poor correlation of PIP and PPO with documented ADEs leading to physical harm.

CONCLUSIONS

This literature is limited by its inconsistent and highly variable outcomes. The majority of medication safety studies in primary care were in high-risk populations and measured potential harms rather than actual harms. Applying algorithms to primary care medication lists significantly overestimates rate of actual harms.

Developing a Multifaceted Evaluation Tool for Electronic Prescribing System: A Study from a Developing Country

: Evaluation of electronic prescribing systems (EPS) can contribute to their quality assurance, and motivate users and policy-makers to implement these systems, directly influencing the health of society. An appropriate evaluation tool plays a determining role in the identification of proper EPS. The present study aimed to develop a multifaceted evaluation tool for assessing the EPS. This study was conducted in two main steps in 2018. In the first step, we conducted a literature review to find the main features and capabilities of the prosperous EPS. In the second step, a Delphi method was used for determining the final criteria for evaluating EPS. After preparing a primary questionnaire based on the first step results, 27 expert stakeholders from related fields participated in this 3-phase Delphi study. The narrative content analysis and descriptive statistics were used for data analysis. The final evaluation tool consists of 61 questions in 10 main dimensions, including practical capabilities of the process/user and patient safety, data storage and transfer, prescription control and renewal, technical functions, user interfaces, security and privacy, reporting, portability, hardware and infrastructure, and system failure/recovery. The evaluation tool developed in this study can be used for the critical appraisal of features of EPS. It is recommended that this multifaceted evaluation tool be employed to help buyers compare different systems and assist EPS software vendors in prioritizing their activities regarding the system development. By using this tool, healthcare organizations can also choose a system that improves many aspects of health care.

VISEMURE: A Visual Analytics System for Making Sense of Multimorbidity Using Electronic Medical Record Data

Multimorbidity is a growing healthcare problem, especially for aging populations. Traditional single disease-centric approaches are not suitable for multimorbidity, and a holistic framework is required for health research and for enhancing patient care. Patterns of multimorbidity within populations are complex and difficult to communicate with static visualization techniques such as tables and charts. We designed a visual analytics system called VISEMURE that facilitates making sense of data collected from patients with multimorbidity. With VISEMURE, users can interactively create different subsets of electronic medical record data to investigate multimorbidity within different subsets of patients with pre-existing chronic diseases. It also allows the creation of groups of patients based on age, gender, and socioeconomic status for investigation. VISEMURE can use a range of statistical and machine learning techniques and can integrate them seamlessly to compute prevalence and correlation estimates for selected diseases. It presents results using interactive visualizations to help healthcare researchers in making sense of multimorbidity. Using a case study, we demonstrate how VISEMURE can be used to explore the high-dimensional joint distribution of random variables that describes the multimorbidity present in a patient population.

Effect of Electronic Prescribing Compared to Paper-Based (Handwritten) Prescribing on Primary Medication Adherence in an Outpatient Setting: A Systematic Review

BACKGROUND

Electronic prescriptions are often created and delivered electronically to the pharmacy while paper-based/handwritten prescriptions may be delivered to the pharmacy by the patients. These differences in the mode of creation and transmission of the two types of prescription could influence the rate at which outpatients fill new prescriptions of previously untried medications.

OBJECTIVES

This study aimed to evaluate literatures to determine the impact of electronic prescribing compared with paper-based/handwritten prescribing on primary medication adherence in an outpatient setting.

METHODS

The keywords and phrases "outpatients," "e-prescriptions," "paper-based prescriptions," and "primary medication adherence" were combined with their relevant synonyms and medical subject headings. A comprehensive literature search was conducted on EMBASE, CINAHL, and MEDLINE databases, and Google Scholar. The results of the search were screened and selected using predefined inclusion and exclusion criteria. The Critical Appraisal Skills Program (CASP) was used for quality appraisal of included studies. Data relevant to the objective of the review were extracted and analyzed through narrative synthesis.

RESULTS

A total of 10 original studies were included in the final review, including 1 prospective randomized study and 9 observational studies. Nine of the 10 studies were performed in the United States. Four of the studies indicated that electronic prescribing significantly increases initial medication adherence, while four of the studies suggested the opposite. The remaining two studies found no significant difference in primary medication adherence between the two methods of prescribing. The variations in the studies did not allow the homogeneity required for meta-analysis to be achieved.

CONCLUSION

The conflicting findings relating to the efficacy of primary medication adherence across both systems demonstrate the need for a standardized measure of medication adherence. This would help further determine the respective benefits of both approaches. Future research should also be conducted in different countries to give a more accurate representation of adherence.

Predicting Acute Kidney Injury: A Machine Learning Approach Using Electronic Health Records

Acute kidney injury (AKI) is a common complication in hospitalized patients and can result in increased hospital stay, health-related costs, mortality and morbidity. A number of recent studies have shown that AKI is predictable and avoidable if early risk factors can be identified by analyzing Electronic Health Records (EHRs). In this study, we employ machine learning techniques to identify older patients who have a risk of readmission with AKI to the hospital or emergency department within 90 days after discharge. One million patients’ records are included in this study who visited the hospital or emergency department in Ontario between 2014 and 2016. The predictor variables include patient demographics, comorbid conditions, medications and diagnosis codes. We developed 31 prediction models based on different combinations of two sampling techniques, three ensemble methods, and eight classifiers. These models were evaluated through 10-fold cross-validation and compared based on the AUROC metric. The performances of these models were consistent, and the AUROC ranged between 0.61 and 0.88 for predicting AKI among 31 prediction models. In general, the performances of ensemble-based methods were higher than the cost-sensitive logistic regression. We also validated features that are most relevant in predicting AKI with a healthcare expert to improve the performance and reliability of the models. This study predicts the risk of AKI for a patient after being discharged, which provides healthcare providers enough time to intervene before the onset of AKI.

Multiple Regression Analysis and Frequent Itemset Mining of Electronic Medical Records: A Visual Analytics Approach Using VISA_M3R3

Medication-induced acute kidney injury (AKI) is a well-known problem in clinical medicine. This paper reports the first development of a visual analytics (VA) system that examines how different medications associate with AKI. In this paper, we introduce and describe VISA_M3R3, a VA system designed to assist healthcare researchers in identifying medications and medication combinations that associate with a higher risk of AKI using electronic medical records (EMRs). By integrating multiple regression models, frequent itemset mining, data visualization, and human-data interaction mechanisms, VISA_M3R3 allows users to explore complex relationships between medications and AKI in such a way that would be difficult or sometimes even impossible without the help of a VA system. Through an analysis of 595 medications using VISA_M3R3, we have identified 55 AKI-inducing medications, 24,212 frequent medication groups, and 78 medication groups that are associated with AKI. The purpose of this paper is to demonstrate the usefulness of VISA_M3R3 in the investigation of medication-induced AKI in particular and other clinical problems in general. Furthermore, this research highlights what needs to be considered in the future when designing VA systems that are intended to support gaining novel and deep insights into massive existing EMRs.

Communication failure: analysis of prescribers' use of an internal free-text field on electronic prescriptions

Importance

Electronic prescribing promises to improve the safety and clarity of prescriptions. However, it also can introduce miscommunication between prescribers and pharmacists. There are situations where information that is meant to be sent to pharmacists is not sent to them, which has the potential for dangerous errors.

Objective

To examine how frequently prescribers or administrative personnel put information intended for pharmacists in a field not sent to pharmacists, classify the type of information included, and assess the potential harm associated with these missed messages.

Design, Setting, Participants

Medication record data from our legacy electronic health record were requested for ambulatory care patients seen at an academic medical center from January 1, 2000, to May 31, 2015 (20 123 881 records). From this database, 6 060 272 medication orders met our inclusion criteria. We analyzed a random sample of 10 000 medication orders with internal comments.

Main Outcomes and Measures

Reviewers classified internal comments for intent. Comments intended for pharmacists were also sorted into descriptive categories and analyzed for the potential for patient harm.

Results

We found that 11.7% of the prescriptions in our sample contained comments that were intended to be sent to pharmacists. Many comments contained information about the dose, route, or duration of the prescription (38.0%). Approximately a third of the comments intended for pharmacists contained information that had the potential for significant or severe harm if not communicated.

Conclusion

We found undelivered comments that were clearly intended for pharmacists and contained important information for either pharmacists or patients. This poses a legitimate safety concern, as a portion of comments contained information that could have prevented severe or significant harm.

Prevalence and Sources of Errors in Positive Airway Pressure Therapy Provisioning

STUDY OBJECTIVES

The prevalence and mechanism of medication errors have been well characterized in the literature. However, no prior studies have investigated the frequency and characteristics of errors in the positive airway pressure (PAP) therapy provisioning process when treating patients with sleep-disordered breathing. Just as medication errors may result in unwanted outcomes, it might be anticipated that errors in providing PAP to patients might lead to suboptimal outcomes. Our study seeks to examine the characteristics and frequency of PAP provisioning errors.

METHODS

This was a retrospective analysis of a cohort of patients in whom sleep-disordered breathing had been diagnosed and subsequently PAP therapy was prescribed. At a 90-day return visit, the PAP therapy the patient was receiving was compared with the intended therapy. Discrepancies were categorized as either prescribing errors (the prescription did not match the intended modality or settings), or setup errors (the modality or settings did not match the prescription).

RESULTS

The overall PAP provisioning error rate was 8%, with errors most commonly occurring during the set-up process. In univariate analysis, insurance type (P = .003), treatment modality (P = .002), and device brand (P = .05) were associated with error and remained significant in multivariate analysis (model fit P = .002). Compliance, residual AHI, and difference in Epworth Sleepiness Scale were not affected by the presence of error.

CONCLUSIONS

PAP provisioning errors are common and might contribute to poor treatment outcomes. Errors might be reduced by standardizing terminology across devices, standardizing prescription forms to improve clarity, and by enhanced quality assurance at durable medical equipment suppliers.

Physicians' Perceptions of Electronic Prescribing with Electronic Medical Records in Kuwaiti Primary Healthcare Centres

Objectives

This study aimed to evaluate physicians' perceptions of electronic prescribing in Kuwaiti primary healthcare centres.

Methods

This cross-sectional study was conducted between June and August 2017 among 368 physicians from 25 primary healthcare centres in Kuwait. Data were collected from the participants using a self-reported questionnaire, including sociodemographic characteristics, previous experience with computers and awareness, knowledge and use of e-prescribing systems and their functional features. In addition, perceptions of the benefits and levels of satisfaction associated with e-prescribing were explored.

Results

A total of 306 physicians completed the survey (response rate: 83%). The majority had positive perceptions regarding the use of e-prescribing, particularly in terms of time-savings (86%), healthcare quality (84%), productivity (80%) and clinical workflow and efficiency (83%). However, many respondents indicated that e-prescribing systems required additional improvements in terms of functionality.

Conclusion

Most physicians in primary healthcare centres in Kuwait recognised the importance of e-prescribing to improve the quality of patient care, streamline workflow, increase productivity and reduce medical errors. However, there is a need to improve the design and infrastructure of e-prescribing systems, which may aid in the adoption of such systems in Kuwait.

Using Electronic Health Records to Identify Adverse Drug Events in Ambulatory Care: A Systematic Review

OBJECTIVE

We identified the methods used and determined the roles of electronic health records (EHRs) in detecting and assessing adverse drug events (ADEs) in the ambulatory setting.

METHODS

We performed a systematic literature review by searching PubMed and Google Scholar for studies on ADEs detected in the ambulatory setting involving any EHR use published before June 2017. We extracted study characteristics from included studies related to ADE detection methods for analysis.

RESULTS

We identified 30 studies that evaluated ADEs in an ambulatory setting with an EHR. In 27 studies, EHRs were used only as the data source for ADE identification. In two studies, the EHR was used as both a data source and to deliver decision support to providers during order entry. In one study, the EHR was a source of data and generated patient safety reports that researchers used in the process of identifying ADEs. Methods of identification included manual chart review by trained nurses, pharmacists, and/or physicians; prescription review; computer monitors; electronic triggers; International Classification of Diseases codes; natural language processing of clinical notes; and patient phone calls and surveys. Seven studies provided examples of search phrases, laboratory values, and rules used to identify ADEs.

CONCLUSION

The majority of studies examined used EHRs as sources of data for ADE detection. This retrospective approach is appropriate to measure incidence rates of ADEs but not adequate to detect preventable ADEs before patient harm occurs. New methods involving computer monitors and electronic triggers will enable researchers to catch preventable ADEs and take corrective action.

Usability aspects of medication-related decision support systems in the outpatient setting: A systematic literature review

In this study, we evaluated the usability aspects of medication-related clinical decision support systems in the outpatient setting. Articles published between 2000 and 2016 in Scopus, PubMed and EMBASE were searched and classified into three usability aspects: Effectiveness, Efficiency and Satisfaction. Using Van Welie et al.’s usability model, we categorized usability aspects in terms of usage indicators and means. Out of the 1999 articles, 24 articles met the selection criteria of which the main focus was on reducing inappropriate medication, prescription rate and prescription errors. Evidence could mainly be found for Effectiveness and showed high rates of positive results in reducing medication errors. To date, the effects of Efficiency and Satisfaction of clinical decision support systems regarding medication prescription remain understudied. Usability aspects such as memorability, learnability, adaptability, shortcuts and consistency require more attention. Studies are needed for better insight into the user model and to design a knowledge/task model for clinical decision support systems regarding medication prescription.

Automatic Errors: A Case Series on the Errors Inherent in Electronic Prescribing

The adoption of electronic prescribing is on the rise, as it reduces medication errors compared to handwritten orders. The inadvertent dispensing of discontinued medications is a type of medication error that is less well described, but one that can lead to adverse events. Software for electronic prescriptions transmits orders for refills or new prescriptions, but not discontinuations, to the pharmacy. Medications that have been stopped are displayed only at the prescribing facility's electronic medical record (EMR). This report describes five cases in which the pharmacy dispensed electronically discontinued medications, two of which contributed to adverse outcomes.

Methods to reduce prescribing errors in elderly patients with multimorbidity

The global population of multimorbid older people is growing steadily. Multimorbidity is the principal cause of complex polypharmacy, which in turn is the prime risk factor for inappropriate prescribing and adverse drug reactions and events. Those who prescribe for older frailer multimorbid people are particularly prone to committing prescribing errors of various kinds. The causes of prescribing errors in this patient population are multifaceted and complex, including prescribers' lack of knowledge of aging physiology, geriatric medicine, and geriatric pharmacotherapy, overprescribing that frequently leads to major polypharmacy, inappropriate prescribing, and inappropriate drug omission. This review examines the various ways of minimizing prescribing errors in multimorbid older people. The role of education in physician prescribers and clinical pharmacists, the use of implicit and explicit prescribing criteria designed to improve medication appropriateness in older people, and the application of information and communication-technology systems to minimize errors are discussed in detail. Although evidence to support any single intervention to prevent prescribing errors in multimorbid elderly people is inconclusive or lacking, published data support focused prescriber education in geriatric pharmacotherapy, routine application of STOPP/START (screening tool of older people's prescriptions/screening tool to alert to right treatment) criteria for potentially inappropriate prescribing, electronic prescribing, and close liaison between clinical pharmacists and physicians in relation to structured medication review and reconciliation. Carrying out a structured medication review aimed at optimizing pharmacotherapy in this vulnerable patient population presents a major challenge. Another challenge is to design, build, validate, and test by clinical trials suitably versatile and efficient software engines that can reliably and swiftly perform complex medication reviews in older multimorbid people. The European Union-funded SENATOR and OPERAM clinical trials commencing in 2016 will examine the impact of customized software engines in reducing medication-related morbidity, avoidable excess cost, and rehospitalization in older multimorbid people.

Electronic Health Records: Then, Now, and in the Future

OBJECTIVES

Describe the state of Electronic Health Records (EHRs) in 1992 and their evolution by 2015 and where EHRs are expected to be in 25 years. Further to discuss the expectations for EHRs in 1992 and explore which of them were realized and what events accelerated or disrupted/derailed how EHRs evolved.

METHODS

Literature search based on "Electronic Health Record", "Medical Record", and "Medical Chart" using Medline, Google, Wikipedia Medical, and Cochrane Libraries resulted in an initial review of 2,356 abstracts and other information in papers and books. Additional papers and books were identified through the review of references cited in the initial review.

RESULTS

By 1992, hardware had become more affordable, powerful, and compact and the use of personal computers, local area networks, and the Internet provided faster and easier access to medical information. EHRs were initially developed and used at academic medical facilities but since most have been replaced by large vendor EHRs. While EHR use has increased and clinicians are being prepared to practice in an EHR-mediated world, technical issues have been overshadowed by procedural, professional, social, political, and especially ethical issues as well as the need for compliance with standards and information security. There have been enormous advancements that have taken place, but many of the early expectations for EHRs have not been realized and current EHRs still do not meet the needs of today's rapidly changing healthcare environment.

CONCLUSION

The current use of EHRs initiated by new technology would have been hard to foresee. Current and new EHR technology will help to provide international standards for interoperable applications that use health, social, economic, behavioral, and environmental data to communicate, interpret, and act intelligently upon complex healthcare information to foster precision medicine and a learning health system.

The pharmacist and the EHR

The adoption of electronic health records (EHRs) across the United States has impacted the methods by which health care professionals care for their patients. It is not always recognized, however, that pharmacists also actively use advanced functionality within the EHR. As critical members of the health care team, pharmacists utilize many different features of the EHR. The literature focuses on 3 main roles: documentation, medication reconciliation, and patient evaluation and monitoring. As health information technology proliferates, it is imperative that pharmacists' workflow and information needs are met within the EHR to optimize medication therapy quality, team communication, and patient outcomes.

Analysis of National Drug Code Identifiers in Ambulatory E-Prescribing

BACKGROUND

Communication of an accurate and interpretable drug identifier between prescriber and pharmacist is critically important for realizing the potential benefits of electronic prescribing (e-prescribing) while minimizing its risk. The National Drug Code (NDC) is the most commonly used codified drug identifier in ambulatory care e-prescribing, but concerns have been raised regarding its use for this purpose. 

OBJECTIVES

To (a) assess the frequency of NDC identifier transmission in ambulatory e-prescribing; (b) characterize the type of NDC identifier transmitted (representative, repackaged, obsolete, private label, and unit dose); and (c) assess the level of agreement between drug descriptions corresponding to NDC identifiers in electronic prescriptions (e-prescriptions) and the free-text drug descriptions that were entered by prescribers. 

METHODS

We analyzed a sample of 49,997 e-prescriptions that were transmitted by ambulatory care prescribers to outlets of a national retail drugstore chain during a single day in April 2014. The First Databank MedKnowledge drug database was used as the primary reference data base to assess the frequency and types of NDC numbers in the e-prescription messages. The FDA's Comprehensive NDC Standard Product Labeling Data Elements File and the National Library of Medicine's RxNorm data file were used as secondary and tertiary references, respectively, to identify NDC numbers that could not be located in the primary reference file. Three experienced reviewers compared the free-text drug description that had been entered by the prescriber with the drug description corresponding to the NDC number from 1 of the 3 reference database files to identify discrepancies. Two licensed pharmacists with residency training and ambulatory care experience served as final adjudicators.

RESULTS

A total of 42,602 e-prescriptions contained a value in the NDC field, of which 42,335 (84.71%) were found in 1 of the 3 study reference databases and were thus considered to be valid NDC numbers. A total of 28,172 (67.70%) e-prescriptions in the sample were found to contain a representative NDC number, according to the definition used by the National Council for Prescription Drug Programs (NCPDP). The remaining e-prescriptions consisted of 4 subtypes of unrepresentative NDC numbers. In 41,298 (97.55%) e-prescriptions that contained an NDC number, the drug description associated with the number from 1 of the 3 data source files pointed to the identical semantic drug concept as the free-text drug description that had been entered by the prescriber. However, in 87 (0.21%) e-prescriptions, the free-text drug descriptions and the drug description associated with the NDC number pointed to completely different semantic drug concepts.

CONCLUSIONS

We found the use of NDC identifiers in our sample of e-prescriptions to be relatively high. However, approximately one-third consisted of unrepresentative NDC numbers (obsolete, repackaged, unit dose, or private label) that have the potential to create workflow disruptions at the dispensing pharmacy. Most disturbing was our finding that more than 2 out of every 1,000 e-prescriptions in our sample contained a free-text drug description that pointed to a completely different drug concept than that associated with its NDC value. Our study suggests the need for e-prescribing technology vendors to maintain accurate and up-to-date drug database files within their systems and to conduct regular validation checks to ensure that the drug descriptions associated with the NDC identifier and the free-text drug description that is sent in the e-prescription message point to the same drug concept. The FDA may need to consider a more active role in ensuring the accuracy of NDC assignment by drug manufacturers.

Causes and consequences of e-prescribing errors in community pharmacies

Major national policy forces are promoting the adoption and use of health information technology (health IT) to improve the quality, safety, and efficiency of health care delivery. One such health IT is electronic prescribing (e-prescribing), which is the direct transmission of prescription information from a provider to a pharmacy. Given research showing that handwritten prescriptions are unsafe and associated errors can lead to tremendous inefficiency for patients and pharmacists, e-prescribing has many potential benefits. However, as with the introduction of any new technology, unintended, adverse consequences may result. The purpose of this review is to explore the causes and consequences of e-prescribing errors in community pharmacies, which are pharmacies not affiliated with a hospital or clinic. Many new types of errors - including provider order entry errors, transcription errors, and dispensing errors - appear to result from e-prescribing. These lead to important consequences for pharmacies, including safety threats to patients, reduced efficiency for pharmacists, processing delays, and increased pharmacy cost. Increased attention to system design and pharmacist training, as well as additional research in this area, will be critical to realize the full benefits of e-prescribing.

Impact of Early Electronic Prescribing on Pharmacists' Clarification Calls in Four Community Pharmacies Located in St John's, Newfoundland

Background

Electronic prescribing (e-prescribing) can potentially help prevent medication errors. As the use of e-prescribing increases across Canada, understanding the benefits and gaps of early e-prescribing can help inform deployment of future e-prescribing systems.

Objective

The purpose of this exploratory study was to determine the prevalence of, reasons for, and average time taken for pharmacist clarification calls to prescribers for electronic medical record (EMR)-generated and handwritten prescriptions.

Methods

Four community pharmacies in St John’s, Newfoundland, Canada prospectively collected information on clarification calls to prescribers for new prescriptions over a period of 17 to 19 weeks. Four semistructured interviews were conducted following the data collection period to gain further insight.

Results

An estimated 1.33% of handwritten prescriptions required clarification compared with 0.66% of EMR-generated prescriptions. Overall, 1.11% of prescriptions required clarification with the prescriber. While illegibility was eliminated with EMR-generated prescriptions, clarification was still required for missing information (24%) and appropriateness (51%). Key themes, including errors unique to EMR-generated prescriptions, emerged from the qualitative interviews.

Conclusions

Advanced e-prescribing functionality will enable secure transmission of prescriptions from prescribers to a patient’s pharmacy of choice through a provincial electronic Drug Information System (DIS)/Pharmacy Network, which will lessen the need for clarification calls, especially in the domains of missing information and appropriateness of the prescription. This exploratory study provides valuable insight into the benefits and gaps of early e-prescribing. Advanced e-prescribing systems will provide an opportunity for further realization of quality and safety benefits related to medication prescribing.

Building a better safety net: taking the safety agenda to office-based women's health

The recent focus on health care safety is a response to the central ethical tenet of medicine--to do no harm. The delivery of safe hospital care has led to demonstrable reductions in medical errors, adverse events, and patient injuries. These improvements have led to a commensurate reduction of legal risk and the emotional toll on caregivers as well as families. It also has reinvigorated the reason many physicians went into medicine--to make a difference for women's health. The new, voluntary Safety Certification in Outpatient Practice Excellence (SCOPE) for Women's Health program of the American Congress of Obstetricians and Gynecologists is a means to both evaluate and recognize work in a critical but often neglected arena--the outpatient setting. It builds on infrastructure created for safety programs in hospital settings. Strong physician leadership, the development of an office culture committed to safety, communication and teamwork skills, safety programs for office-based surgery, medication safety, and tracking systems are all important for safe treatment of our patients in the office setting. The SCOPE Program defines the necessary safety goals for ambulatory women's health care and provides an educational pathway to reach those goals. SCOPE certification is an achievement recognizing the commitment of physicians and their staff to the health and safety of their patients.

Capture and documentation of coded data on adverse drug reactions: an overview

Allergic responses to prescription drugs are largely preventable, and incur significant cost to the community both financially and in terms of healthcare outcomes. The capacity to minimise the effects of repeated events rests predominantly with the reliability of allergy documentation in medical records and computerised physician order entry systems (CPOES) with decision support such as allergy alerts. This paper presents an overview of the nature and extent of adverse drug reactions (ADRs) in Australia and other developed countries, a discussion and evaluation of strategies which have been devised to address this issue, and a commentary on the role of coded data in informing this patient safety issue. It is not concerned with pharmacovigilance systems that monitor ADRs on a global scale. There are conflicting reports regarding the efficacy of these strategies. Although in many cases allergy alerts are effective, lack of sensitivity and contextual relevance can often induce doctors to override alerts. Human factors such as user fatigue and inadequate adverse drug event reporting, including ADRs, are commonplace. The quality of and response to allergy documentation can be enhanced by the participation of nurses and pharmacists, particularly in medication reconciliation. The International Classification of Diseases (ICD) coding of drug allergies potentially yields valuable evidence, but the quality of local and national level coded data is hampered by under-documenting and under-coding.

Evaluation of medium-term consequences of implementing commercial computerized physician order entry and clinical decision support prescribing systems in two 'early adopter' hospitals

OBJECTIVE

To understand the medium-term consequences of implementing commercially procured computerized physician order entry (CPOE) and clinical decision support (CDS) systems in 'early adopter' hospitals.

MATERIALS AND METHODS

In-depth, qualitative case study in two hospitals using a CPOE or a CDS system for at least 2 years. Both hospitals had implemented commercially available systems. Hospital A had implemented a CPOE system (with basic decision support), whereas hospital B invested additional resources in a CDS system that facilitated order entry but which was integrated with electronic health records and offered more advanced CDS. We used a combination of documentary analysis of the implementation plans, audiorecorded semistructured interviews with system users, and observations of strategic meetings and systems usage.

RESULTS

We collected 11 documents, conducted 43 interviews, and conducted a total of 21.5 h of observations. We identified three major themes: (1) impacts on individual users, including greater legibility of prescriptions, but also some accounts of increased workloads; (2) the introduction of perceived new safety risks related to accessibility and usability of hardware and software, with users expressing concerns that some problems such as duplicate prescribing were more likely to occur; and (3) realizing organizational benefits through secondary uses of data.

CONCLUSIONS

We identified little difference in the medium-term consequences of a CPOE and a CDS system. It is important that future studies investigate the medium- and longer-term consequences of CPOE and CDS systems in a wider range of hospitals.

The effects of electronic prescribing by community-based providers on ambulatory medication safety

BACKGROUND

US federal policies are incentivizing use of electronic prescribing (e-prescribing) to improve safety. However, little is known about e-prescribing's actual impact on medication safety over time. A study was conducted to assess the effect of implementing a commercial electronic health record (EHR) with e-prescribing on rates and types of prescribing errors. Understanding safety effects from e-prescribing will be important as providers increasingly e-prescribe.

METHODS

Prescriptions written by 20 community-based primary care providers in the Hudson Valley region of New York from November 2008 to November 2009 were retrospectively studied. All providers adopted a commercial EHR with robust clinical decision support and extensive technical support to aid in prescribing. Errors were identified by standardized prescription and chart review.

RESULTS

Some 1,629 prescriptions were analyzed at three months postimplementation, and 1,738 prescriptions were analyzed at one year postimplementation. Use of e-prescribing resulted in relatively low error rates (6.0 errors per 100 prescriptions). These rates were sustained over time but without further improvement (6.0 versus 4.5 errors per 100 prescriptions, p = .15). Antibiotics were the class of medications most frequently involved (12.7% of overall errors), and direction errors were most common (24% of errors).

CONCLUSIONS

This study is the first, as far as known, to quantitatively evaluate prescribing errors early after EHR implementation and after sustained use among community-based primary care providers. Relatively low rates of errors with e-prescribing were found early and after prolonged use. Extensive support for providers before, during, and after implementation may mitigate potential safety threats from implementation of an EHR system and result in sustained safety benefits over the long-term.

Anaphylaxis challenges on the front line: perspectives from community medicine

This report reflects a discussion from the multidisciplinary Partnership for Anaphylaxis Round Table meeting, held in November 2012, in Dallas, Texas. Community medicine participants included John R. Bennett, MD, an internist who practiced in Cumming, Georgia, and whose patients were adults; Leonard Fromer, MD, a family practitioner in Los Angeles, California, who was the medical director of a network of 600 medical groups, including pediatricians, internists, and family physicians, and who in his previous practice treated children and adults, many of them with severe allergies; and Mary Lou Hayden, MS, RN, FNP-BC, AE-C, a nurse practitioner who treated adults in a university employee health clinic and in an allergy clinic in Charlottesville, Virginia, and whose prior practice focused on allergy and immunology in children and adults. This discussion was moderated by Dr Bennett. Participants provided their perspectives as primary care providers (PCPs) concerning anaphylaxis, which has become a major public health concern. The rising prevalence of severe allergies and incidence of anaphylaxis and other severe allergic reactions among children and adults is shifting more care to PCPs. This discussion provides insights into challenges faced by PCPs in treating patients at risk for anaphylaxis in the community setting and provides potential solutions to those challenges.

From physician intent to the pharmacy label: prevalence and description of discrepancies from a cross-sectional evaluation of electronic prescriptions

OBJECTIVE

The objectives of this cross-sectional study were to estimate the prevalence of unintended discrepancies between three sources of prescription information and to describe the types of electronic prescribing system vulnerabilities identified.

METHODS

Staff from community pharmacies identified approximately 200 new prescriptions written at three participating ambulatory care clinics (2 adult, 1 paediatric). Unintended discrepancies were identified by comparing three sources of prescription information: (1) the prescriber's note as documented in the patient's chart; (2) the electronic prescription (e-prescription) entered into the clinic's electronic prescribing software; (3) the medication that was ultimately dispensed by the pharmacy as indicated on the prescription label. The discrepancy rate was calculated by dividing the number of discrepancies identified by the number of prescriptions evaluated.

RESULTS

A total of 602 prescriptions written by 33 prescribers were evaluated from the 3 ambulatory care clinics. The discrepancy rate between the prescriber's note and the e-prescription was 1.7%, 0.6% and 3.9% for the three clinics. The discrepancy rate between the e-prescription (clinic) and the prescription label (pharmacy) was 4.2%, 0.9% and 1.5%. Differences between directions for administration was the most common type of discrepancy identified.

CONCLUSIONS

Discrepancy rates between the prescriber's note and the e-prescription were similar to the discrepancy rates between the e-prescription and pharmacy label. To reduce outpatient medication errors, a better understanding is needed of the sources of discrepancies that occur within the prescriber's clinic, and those that occur between the clinic and pharmacy.

Variation in electronic health record adoption and readiness for meaningful use: 2008-2011

BACKGROUND

Federal initiatives are underway that provide physicians with financial incentives for meaningful use (MU) of electronic health records (EHRs) and assistance to purchase and implement EHRs.

OBJECTIVE

We sought to examine readiness and interest in MU among primary care physicians and specialists, and identify factors that may affect their readiness to obtain MU incentives.

DESIGN/PARTICIPANTS

We analyzed 4 years of data (2008-2011) from the National Ambulatory Medical Care Survey (NAMCS) Electronic Medical Record (EMR) Supplement, an annual cross-sectional nationally representative survey of non-federally employed office-based physicians.

MAIN MEASURES

Survey-weighted EHR adoption rates, potential to meet selected MU criteria, and self-reported intention to apply for MU incentives. We also examined the association between physician and practice characteristics and readiness for MU.

KEY RESULTS

The overall sample consisted of 10,889 respondents, with weighted response rates of 62 % (2008); 74 % (2009); 66 % (2010); and 61 % (2011). Primary care physicians' adoption of EHRs with the potential to meet MU nearly doubled from 2009 to 2011 (18 % to 38 %, p<0.01), and was significantly higher than specialists (19 %) in 2011 (p<0.01). In 2011, half of physicians (52 %) expressed their intention to apply for MU incentives; this did not vary by specialty. Multivariate analyses report that EHR adoption was significantly higher in both 2010 and 2011 compared to 2009, and primary care physicians and physicians working in larger or multi-specialty practices or for HMOs were more likely to adopt EHRs with the potential to meet MU.

CONCLUSIONS

Physician EHR adoption rates increased in advance of MU incentive payments. Although interest in MU incentives did not vary by specialty, primary care physicians had significantly higher rates of adopting EHRs with the potential to meet MU. Addressing barriers to EHR adoption, which may vary by specialty, will be important to enhancing coordination of care.

Hospital workers' perceptions of waste: a qualitative study involving photo-elicitation

OBJECTIVES

To elicit sources of waste as viewed by hospital workers.

DESIGN

Qualitative study using photo-elicitation, an ethnographic technique for prompting in-depth discussion.

SETTING

U.S. academic tertiary care hospital.

PARTICIPANTS

Physicians, nurses, pharmacists, administrative support personnel, administrators and respiratory therapists.

METHODS

A purposive sample of personnel at an academic tertiary care hospital was invited to take up to 10 photos of waste. Participants discussed their selections using photos as prompts during in-depth interviews. Transcripts were analysed in an iterative process using grounded theory; open and axial coding was performed, followed by selective and thematic coding to develop major themes and subthemes.

RESULTS

Twenty-one participants (nine women, average number of years in field=19.3) took 159 photos. Major themes included types of waste and recommendations to reduce waste. Types of waste comprised four major categories: Time, Materials, Energy and Talent. Participants emphasised time wastage (50% of photos) over other types of waste such as excess utilisation (2.5%). Energy and Talent were novel categories of waste. Recommendations to reduce waste included interventions at the micro-level (eg, individual/ward), meso-level (eg, institution) and macro-level (eg, payor/public policy).

CONCLUSIONS

The waste hospital workers identified differed from previously described waste both in the types of waste described and the emphasis placed on wasted time. The findings of this study represent a possible need for education of hospital workers about known types of waste, an opportunity to assess the impact of novel types of waste described and an opportunity to intervene to reduce the waste identified.

A long-term follow-up evaluation of electronic health record prescribing safety

OBJECTIVE

To be eligible for incentives through the Electronic Health Record (EHR) Incentive Program, many providers using older or locally developed EHRs will be transitioning to new, commercial EHRs. We previously evaluated prescribing errors made by providers in the first year following transition from a locally developed EHR with minimal prescribing clinical decision support (CDS) to a commercial EHR with robust CDS. Following system refinements, we conducted this study to assess the rates and types of errors 2 years after transition and determine the evolution of errors.

MATERIALS AND METHODS

We conducted a mixed methods cross-sectional case study of 16 physicians at an academic-affiliated ambulatory clinic from April to June 2010. We utilized standardized prescription and chart review to identify errors. Fourteen providers also participated in interviews.

RESULTS

We analyzed 1905 prescriptions. The overall prescribing error rate was 3.8 per 100 prescriptions (95% CI 2.8 to 5.1). Error rates were significantly lower 2 years after transition (p<0.001 compared to pre-implementation, 12 weeks and 1 year after transition). Rates of near misses remained unchanged. Providers positively appreciated most system refinements, particularly reduced alert firing.

DISCUSSION

Our study suggests that over time and with system refinements, use of a commercial EHR with advanced CDS can lead to low prescribing error rates, although more serious errors may require targeted interventions to eliminate them. Reducing alert firing frequency appears particularly important. Our results provide support for federal efforts promoting meaningful use of EHRs.

CONCLUSIONS

Ongoing error monitoring can allow CDS to be optimally tailored and help achieve maximal safety benefits.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov, Identifier: NCT00603070.

Assessment of efficiency and safety of the comprehensive Chemotherapy Assistance Program for ordering oncology medications

PURPOSE

To assess whether the newly developed Comprehensive Chemotherapy Assistance Program (CAP) decreases errors and increases performance efficiency in ordering oncology medications as compared to the existing Computerized Physician Order Entry (CPOE) system, the Order Communication System (OCS).

METHODS

All chemotherapy prescriptions ordered using OCS and CAP systems during the first year of CAP implementation were prospectively analyzed to identify near-miss cases. The efficiency outcomes were determined in a trial setting with eight predefined hypothetical chemotherapy regimens, each with four measures of the average time, movement distance on the screen, maximum input interval time, and number of mouse or keystrokes per order. A total of 14 physicians participated in the study, and each regimen was ordered twice, once using CAP and once using OCS.

RESULTS

For all near-miss types, CAP orders showed significant improvements as compared with OCS orders (p<0.0001). For CAP orders, incorrect dose and agent errors were reduced by 43.9% and 31.6%, respectively. Compared with OCS orders, regimen defects, drug omissions, and incorrect data input errors were reduced by more than 70% for CAP orders. For all four efficiency measures, a statistically significant competence was identified when physicians ordered a chemotherapy prescription with CAP as compared with OCS (p<0.0001).

CONCLUSIONS

These results demonstrate the superiority of CAP over the existing CPOE system for ordering oncology medications with regard to safety and efficiency.

Computerized provider order entry and patient safety

Medication errors can lead to significant morbidity and mortality for patients. Children are particularly vulnerable to medication errors. A strategy for reducing medication errors and the harm resulting from these errors is use of computerized provider order entry (CPOE). This article examines the frequency and nature of prescribing errors for pediatric patients. Also discussed are the proposed benefits from CPOE use, including elimination of eligibility errors, ensuring completeness in prescribing fields, reduction in transcription errors, and improved prescribing practices through the use of clinical decision support. The literature on the effect of CPOE in actual use is explored, as are policy implications and directions for future research.

Patient safety in ambulatory care

Understanding of the types and frequency of errors among children in the outpatient setting is paramount. The most commonly described errors involve medical treatment, communication failures, patient identification, laboratory, and diagnostic errors. Research suggests that adverse events and near misses are frequent occurrences in ambulatory pediatrics, but relatively little is known about the types of errors, risk factors, or effective interventions in this setting. This article will review current information on the descriptive epidemiology of pediatric outpatient medical errors, established risk factors for these errors, effective interventions to enhance reporting and improve safety, and future research needs in this area.

Development and field testing of an HIV medication touch screen computer patient adherence tool with telephone-based, targeted adherence counseling

BACKGROUND

HIV medication nonadherence is a major problem, yet many providers lack the time and training to carefully ask patients about their adherence.

OBJECTIVE

To design and pilot a technology-assisted intervention, for use in clinical settings, to identify nonadherent patients.

METHODS

The intervention uses audio computer-assisted self-interview (ACASI) to improve the assessment of adherence and medication-related problems. Patients completed a touch screen computer ACASI which generated graphic clinician and patient reports for discussion during the clinical encounter.

RESULTS

72 patients and 11 providers participated in this study. The patients easily completed the ACASI. Adherence was 63% (3-day) and 47% (30-day). Using the ACASI, 22% of patients identified themselves as nonadherent, when their providers perceived them as adherent.

CONCLUSIONS

This ACASI-based intervention is easy to use and helps identify nonadherence. The pilot test engendered enhancements including the addition of phone-based adherence counseling. A larger trial is underway to evaluate whether the intervention leads to improved HIV-related outcomes.

Predicting and detecting adverse drug reactions in old age: challenges and opportunities

Increased, often inappropriate, drug exposure, pharmacokinetic and pharmacodynamic changes, reduced homeostatic reserve and frailty increase the risk of adverse drug reactions (ADRs) in the older population, thereby imposing a significant public health burden. Predicting and diagnosing ADRs in old age presents significant challenges for the clinician, even when specific risk scoring systems are available. The picture is further compounded by the potential adverse impact of several drugs on more 'global' health indicators, for example, physical function and independence, and the fragmentation of care (e.g., increased number of treating doctors and care transitions) experienced by older patients during their clinical journey. The current knowledge of drug safety in old age is also curtailed by the lack of efficacy and safety data from pre-marketing studies. Moreover, little consideration is given to individual patients' experiences and reporting of specific ADRs, particularly in the presence of cognitive impairment. Pending additional data on these issues, the close review and monitoring of individual patients' drug prescribing, clinical status and biochemical parameters remain essential to predict and detect ADRs in old age. Recently developed strategies, for example, medication reconciliation and trigger tool methodology, have the potential for ADRs risk mitigation in this population. However, more information is required on their efficacy and applicability in different healthcare settings.

Technical support and delegation to practice staff - status quo and (possible) future perspectives for primary health care in Germany

BACKGROUND

Primary health care in industrialized countries faces major challenges due to demographic changes, an increasing prevalence of chronic diseases and a shortage of primary care physicians. One approach to counteract these developments might be to reduce primary care physicians' workload supported by the use of health information technology (HIT) and non-physician practice staff. In 2009, the U.S. Commonwealth Fund (CWF) conducted an international survey of primary care physicians which the present secondary descriptive analysis is based on. The aim of this analysis was twofold: First, to explore to what extend German primary care physicians already get support by HIT and non-physician practice staff, and second, to show possible future perspectives.

METHODS

The CWF questionnaire was sent to a representative random sample of 1,500 primary care physicians all over Germany. The data was descriptively analyzed. Group comparisons regarding differences in gender and age groups were made by means of Chi Square Tests for categorical variables. An alpha-level of p < 0.05 was used for statistical significance.

RESULTS

Altogether 715 primary care physicians answered the questionnaire (response rate 49%). Seventy percent of the physicians use electronic medical records. Technical features such as electronic ordering and access to laboratory parameters are mainly used. However, the majority does not routinely use technical functions for drug prescribing, reminder-systems for guideline-based interventions or recall of patients. Six percent of surveyed physicians are able to transfer prescriptions electronically to a pharmacy, 1% use email communication with patients regularly. Seventy-two percent of primary care physicians get support by non-physician practice staff in patient care, mostly in administrative tasks or routine preventive services. One fourth of physicians is supported in telephone calls to the patient or in patient education and counseling.

CONCLUSION

Within this sample the majority of primary care physicians get support by HIT and non-physician practice staff in their daily work. However, the potential has not yet been fully used. Supportive technical functions like electronic alarm functions for medication or electronic prescribing should be improved technically and more adapted to physicians' needs. To warrant pro-active health care, recall and reminder systems should get refined to encourage their use. Adequately qualified non-physician practice staff could play a more active role in patient care. Reimbursement should not only be linked to doctors', but also to non-physician practice staff services.

Ambulatory prescribing errors among community-based providers in two states

OBJECTIVE

Little is known about the frequency and types of prescribing errors in the ambulatory setting among community-based, primary care providers. Therefore, the rates and types of prescribing errors were assessed among community-based, primary care providers in two states.

MATERIAL AND METHODS

A non-randomized cross-sectional study was conducted of 48 providers in New York and 30 providers in Massachusetts, all of whom used paper prescriptions, from September 2005 to November 2006. Using standardized methodology, prescriptions and medical records were reviewed to identify errors.

RESULTS

9385 prescriptions were analyzed from 5955 patients. The overall prescribing error rate, excluding illegibility errors, was 36.7 per 100 prescriptions (95% CI 30.7 to 44.0) and did not vary significantly between providers from each state (p=0.39). One or more non-illegibility errors were found in 28% of prescriptions. Rates of illegibility errors were very high (175.0 per 100 prescriptions, 95% CI 169.1 to 181.3). Inappropriate abbreviation and direction errors also occurred frequently (13.4 and 4.2 errors per 100 prescriptions, respectively). Reviewers determined that the vast majority of errors could have been eliminated through the use of e-prescribing with clinical decision support.

DISCUSSION

Prescribing errors appear to occur at very high rates among community-based primary care providers, especially when compared with studies of academic-affiliated providers that have found nearly threefold lower error rates. Illegibility errors are particularly problematical.

CONCLUSIONS

Further characterizing prescribing errors of community-based providers may inform strategies to improve ambulatory medication safety, especially e-prescribing.

TRIAL REGISTRATION NUMBER

http://www.clinicaltrials.gov, NCT00225576.