An Observational Study of the Impact of a Computerized Physician Order Entry System on the Rate of Medication Errors in an Orthopaedic Surgery Unit

Automated Drugs Dispensing Systems in Hospitals: a Health Technology Assessment (HTA) Study Across Six European Countries

Background

Automated Drug Dispensing (ADD) systems are considered to be strategic hospital assets used to reduce errors and enhance economic and organizational sustainability. With regards to efficacy and safety, the literature evidence demonstrates the incremental benefits of centralised or decentralised systems compared to manual dispensing. Analyses about organisational and economic sustainability are still lacking and the present study aims to perform a Health Technology Assessment (HTA), producing multidimensional evidence on the use of ADD systems within hospitals.

Methods

In 2023, a comprehensive HTA draws insights from healthcare professionals across six European nations: Italy, France, Germany, the Netherlands, the United Kingdom, and Belgium. This appraisal juxtaposed four drug dispensing scenarios: manual methods, centralized ADD systems, decentralized ADD systems, and integrated solutions employing cutting-edge technologies in both central pharmacies and wards. The study deployed an Activity-Based Costing approach that was combined with a cost-effectiveness and Budget Impact Analysis to evaluate economic impacts. Qualitative questionnaires were implemented to assess ethical, legal, organizational, safety, and efficacy aspects.

Results

From a multidimensional perspective, healthcare professionals acknowledged ADD manifold advantages of ADD systems. From an organizational perspective and within a 12-month timeframe, transitioning to automation may face initial challenges that are attributed to potential resistance from professionals and significant investments. However, 36 months past its adoption, automation's superiority over manual methods was recognized. Economically, savings burgeoned from +17.9% in UK to +26.6% in Belgian hospitals that adopted integrated systems in comparison to traditional manual approaches.

Conclusion

Compared to traditional methods, implementing ADD systems could improve the logistic management of drug in the hospital setting, thereby enhancing safety and efficacy, streamlining the healthcare professionals' workflow, and bolstering financial stability.

The effect of electronic medical records on medication errors, workload, and medical information availability among qualified nurses in Israel- a cross sectional study

BACKGROUND

Errors in medication administration by qualified nursing staff in hospitals are a significant risk factor for patient safety. In recent decades, electronic medical records (EMR) systems have been implemented in hospitals, and it has been claimed that they contribute to reducing such errors. However, systematic research on the subject in Israel is scarce. This study examines the position of the qualified nursing staff regarding the impact of electronic medical records systems on factors related to patient safety, including errors in medication administration, workload, and availability of medical information.

METHODS

This cross-sectional study examines three main variables: Medication errors, workload, and medical information availability, comparing two periods- before and after EMR implementation based on self-reports. A final sample of 591 Israeli nurses was recruited using online private social media groups to complete an online structured questionnaire. The questionnaires included items assessing workload (using the Expanding Nursing Stress Scale), medical information availability (the Carrington-Gephart Unintended Consequences of Electronic Health Record Questionnaire), and medical errors (the Medical Error Checklists). Items were assessed twice, once for the period before the introduction of electronic records and once after. In addition, participants answered open-ended questions that were qualitatively analyzed.

RESULTS

Nurses perceive the EMR as reducing the extent of errors in drug administration (mean difference = -0.92 ± 0.90SD, p < 0.001), as well as the workload (mean difference = -0.83 ± 1.03SD, p < 0.001) by ∼ 30% on average, each. Concurrently, the systems are perceived to require a longer documentation time at the expense of patients' treatment time, and they may impair the availability of medical information by about 10% on average.

CONCLUSION

The results point to nurses' perceived importance of EMR systems in reducing medication errors and relieving the workload. Despite the overall positive attitudes toward EMR systems, nurses also report that they reduce information availability compared to the previous pen-and-paper approach. A need arises to improve the systems in terms of planning and adaptation to the field and provide appropriate technical and educational support to nurses using them.

Reduced prevalence of drug-related problems in psychiatric inpatients after implementation of a pharmacist-supported computerized physician order entry system - a retrospective cohort study

Introduction

In 2021, a computerized physician order entry (CPOE) system with an integrated clinical decision support system (CDSS) was implemented at a tertiary care center for the treatment of mental health conditions in Lübeck, Germany. To date, no study has been reported on the types and prevalence of drug-related problems (DRPs) before and after CPOE implementation in a psychiatric inpatient setting. The aim of this retrospective before-and-after cohort study was to investigate whether the implementation of a CPOE system with CDSS accompanied by the introduction of regular medication plausibility checks by a pharmacist led to a decrease of DRPs during hospitalization and unsolved DRPs at discharge in psychiatric inpatients.

Methods

Medication charts and electronic patient records of 54 patients before (cohort I) and 65 patients after (cohort II) CPOE implementation were reviewed retrospectively by a clinical pharmacist. All identified DRPs were collected and classified based on 'The PCNE Classification V9.1', the German database DokuPIK, and the 'NCC MERP Taxonomy of Medication Errors'.

Results

325 DRPs were identified in 54 patients with a mean of 6 DRPs per patient and 151.9 DRPs per 1000 patient days in cohort I. In cohort II, 214 DRPs were identified in 65 patients with a mean of 3.3 DRPs per patient and 81.3 DRPs per 1000 patient days. The odds of having a DRP were significantly lower in cohort II (OR=0.545, 95% CI 0.412-0.721, p<0.001). The most frequent DRP in cohort I was an erroneous prescription (n=113, 34.8%), which was significantly reduced in cohort II (n=12, 5.6%, p<0.001). During the retrospective in-depth review, more DRPs were identified than during the daily plausibility analyses. At hospital discharge, patients had significantly less unsolved DRPs in cohort II than in cohort I.

Discussion

The implementation of a CPOE system with an integrated CDSS reduced the overall prevalence of DRPs, especially of prescription errors, and led to a smaller rate of unsolved DRPs in psychiatric inpatients at hospital discharge. Not all DRPs were found by plausibility analyses based on the medication charts. A more interactive and interdisciplinary patient-oriented approach might result in the resolution of more DRPs.

Frequency of Medication Administration Timing Error in Hospitals: A Systematic Review

BACKGROUND

Medication administration timing error (MATE) leads to poor medication efficacy, harm, and death. Frequency of MATE is understudied.

PURPOSE

To determine MATE frequency, and characteristics and quality of reporting studies.

METHODS

A systematic review of articles between 1999 and 2021 was conducted using the Cumulative Index of Nursing and Allied Health Literature, ProQuest, and PubMed databases. Articles were scored for quality using the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) checklist.

RESULTS

Initially, 494 articles were screened; 23 were included in this review. MATE was defined as administration beyond 60 minutes before or after the scheduled time in 13 (57%) of the included studies. Measurement procedures included data abstraction, self-report, and observation. Frequency of MATE was 1% to 72.6%. Moderate study quality was found in 78% of articles.

CONCLUSION

Research on MATE is characterized by inconsistent definitions, measurements procedures, and calculation techniques. High-quality studies are lacking. Many research improvement opportunities exist.

Stakeholder perspectives of system-related errors: Types, contributing factors, and consequences

BACKGROUND

Despite growing evidence of the benefits of electronic medication management systems (EMMS), research has also identified a range of new safety risks linked with their use. There is limited qualitative research focusing on system-related errors that result from use of EMMS. The aim of this study was to explore in-depth stakeholders' perceptions and experiences of system-related errors.

METHODS

Semi-structured interviews were conducted with EMMS users and other relevant staff (e.g. supporting roles in EMMS) across a local health district in Sydney, Australia. Analysis was conducted iteratively using a general inductive approach, and then mapped to Reason's accident causation model, where codes were categorized as 1) unsafe acts (i.e. what error occurred), 2) latent conditions (i.e. what factors contributed to errors), and 3) consequences resulting from the error.

RESULTS

Twenty-five participants were interviewed between September 2020 and May 2021. Participants most frequently described omission errors (e.g. failure to check for duplicate orders) as unsafe acts, although commission errors and workarounds were also reported. Poor EMMS design was reported to be a significant workplace factor contributing to system-related errors, however participants also described user factors, such as an overreliance on the system, and organizational factors, such as system downtime, as contributing to errors. Reported consequences of system-related errors included medication errors, but also impacts to the EMMS and on workers.

CONCLUSIONS

EMMS design is a significant contributor to system-related errors, but this research showed that user and organizational factors are also at play. As these factors are not independent, minimizing system-related errors requires a multi-faceted approach, where mitigation strategies target not only the EMMS, but also the context in which the system has been implemented.

Electronic Medication Management Systems: Analysis of Enhancements to Reduce Errors and Improve Workflow

BACKGROUND

Electronic medication management (eMM) has been shown to reduce medication errors; however, new safety risks have also been introduced that are associated with system use. No research has specifically examined the changes made to eMM systems to mitigate these risks.

OBJECTIVES

To (1) identify system-related medication errors or workflow blocks that were the target of eMM system updates, including the types of medications involved, and (2) describe and classify the system enhancements made to target these risks.

METHODS

In this retrospective qualitative study, documents detailing updates made from November 2014 to December 2019 to an eMM system were reviewed. Medication-related updates were classified according to "rationale for changes" and "changes made to the system."

RESULTS

One hundred and seventeen updates, totaling 147 individual changes, were made to the eMM system over the 4-year period. The most frequent reasons for changes being made to the eMM were to prevent medication errors (24% of reasons), optimize workflow (22%), and support "work as done" on paper (16%). The most frequent changes made to the eMM were options added to lists (14% of all changes), extra information made available on the screen (8%), and the wording or phrasing of text modified (8%). Approximately a third of the updates (37%) related to high-risk medications. The reasons for system changes appeared to vary over time, as eMM functionality and use expanded.

CONCLUSION

To our knowledge, this is the first study to systematically review and categorize system updates made to overcome new safety risks associated with eMM use. Optimization of eMM is an ongoing process, which changes over time as users become more familiar with the system and use is expanded to more sites. Continuous monitoring of the system is necessary to detect areas for improvement and capitalize on the benefits an electronic system can provide.

The impact of a computerized physician order entry system implementation on 20 different criteria of medication documentation-a before-and-after study

Background

The medication process is complex and error-prone. To avoid medication errors, a medication order should fulfil certain criteria, such as good readability and comprehensiveness. In this context, a computerized physician order entry (CPOE) system can be helpful. This study aims to investigate the distinct effects on the quality of prescription documentation of a CPOE system implemented on general wards in a large tertiary care hospital.

Methods

In a retrospective analysis, the prescriptions of two groups of 160 patients each were evaluated, with data collected before and after the introduction of a CPOE system. According to nationally available recommendations on prescription documentation, it was assessed whether each prescription fulfilled the established 20 criteria for a safe, complete, and actionable prescription. The resulting fulfilment scores (prescription-Fscores) were compared between the pre-implementation and the post-implementation group and a multivariable analysis was performed to identify the effects of further covariates, i.e., the prescription category, the ward, and the number of concurrently prescribed drugs. Additionally, the fulfilment of the 20 criteria was assessed at an individual criterion-level (denoted criteria-Fscores).

Results

The overall mean prescription-Fscore increased from 57.4% ± 12.0% (n = 1850 prescriptions) before to 89.8% ± 7.2% (n = 1592 prescriptions) after the implementation (p < 0.001). At the level of individual criteria, criteria-Fscores significantly improved in most criteria (n = 14), with 6 criteria reaching a total score of 100% after CPOE implementation. Four criteria showed no statistically significant difference and in two criteria, criteria-Fscores deteriorated significantly. A multivariable analysis confirmed the large impact of the CPOE implementation on prescription-Fscores which was consistent when adjusting for the confounding potential of further covariates.

Conclusions

While the quality of prescription documentation generally increases with implementation of a CPOE system, certain criteria are difficult to fulfil even with the help of a CPOE system. This highlights the need to accompany a CPOE implementation with a thorough evaluation that can provide important information on possible improvements of the software, training needs of prescribers, or the necessity of modifying the underlying clinical processes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01607-6.

How effective are electronic medication systems in reducing medication error rates and associated harm among hospital inpatients? A systematic review and meta-analysis

OBJECTIVE

To conduct a systematic review and meta-analysis to assess: 1) changes in medication error rates and associated patient harm following electronic medication system (EMS) implementation; and 2) evidence of system-related medication errors facilitated by the use of an EMS.

MATERIALS AND METHODS

We searched Medline, Scopus, Embase, and CINAHL for studies published between January 2005 and March 2019, comparing medication errors rates with or without assessments of related harm (actual or potential) before and after EMS implementation. EMS was defined as a computer-based system enabling the prescribing, supply, and/or administration of medicines. Study quality was assessed.

RESULTS

There was substantial heterogeneity in outcomes of the 18 included studies. Only 2 were strong quality. Meta-analysis of 5 studies reporting change in actual harm post-EMS showed no reduced risk (RR: 1.22, 95% CI: 0.18-8.38, P = .8) and meta-analysis of 3 studies reporting change in administration errors found a significant reduction in error rates (RR: 0.77, 95% CI: 0.72-0.83, P = .004). Of 10 studies of prescribing error rates, 9 reported a reduction but variable denominators precluded meta-analysis. Twelve studies provided specific examples of system-related medication errors; 5 quantified their occurrence.

DISCUSSION AND CONCLUSION

Despite the wide-scale adoption of EMS in hospitals around the world, the quality of evidence about their effectiveness in medication error and associated harm reduction is variable. Some confidence can be placed in the ability of systems to reduce prescribing error rates. However, much is still unknown about mechanisms which may be most effective in improving medication safety and design features which facilitate new error risks.

Beyond the numbers: Utilising existing textual data for qualitative research in pharmacy and health services research

INTRODUCTION

Qualitative research is a well-established branch of scientific enquiry that draws insights from experiences.^{1, 2}Within social and administrative pharmacy research, interview and focus group methods are a mainstay of collecting data. However, other disciplines such as sociology, psychology and anthropology, use existing data that is routinely to provide a substance for qualitative inquiry. Drawing on our experiences of using interdisciplinary research methods, this paper presents three case studies where textual data was qualitatively analysed and critically examines the strengths and weaknesses of these method in relation to pharmacy practice.

METHODS

Three case studies were selected that access different types of existing, routinely collected data from pharmacy practice. This included 1) a study utilising boardroom meeting minutes, 2) a study using incident reports and 3) a study using WhatsApp messages as data. Each case study is described and critically examined. The strengths and weaknesses of this approach are based on our own reflections of completing the studies.

RESULTS

Relationships between people, products and organisations can be examined in documents, records and text that is routinely collected. Existing data can also provide insights into culture, working patterns, education and errors. Practical advantages of using existing data include faster data collection and access to first-hand, accounts of experiences of human relationship with pharmaceutical products and practice. Drawbacks of using existing data are that some data may be missing, participants may no longer be accessible for participant checking and the context of language may have changed.

CONCLUSION

This paper critically examined the use of methods rarely used in pharmacy practice research which draw on existing, routinely collected data. Adopting a wider range of data collection methods may will provide new understanding and insights into social and clinical pharmacy practice.

The impact of health information technology on prescribing errors in hospitals: a systematic review and behaviour change technique analysis

BACKGROUND

Health information technology (HIT) is known to reduce prescribing errors but may also cause new types of technology-generated errors (TGE) related to data entry, duplicate prescribing, and prescriber alert fatigue. It is unclear which component behaviour change techniques (BCTs) contribute to the effectiveness of prescribing HIT implementations and optimisation. This study aimed to (i) quantitatively assess the HIT that reduces prescribing errors in hospitals and (ii) identify the BCTs associated with effective interventions.

METHODS

Articles were identified using CINAHL, EMBASE, MEDLINE, and Web of Science to May 2020. Eligible studies compared prescribing HIT with paper-order entry and examined prescribing error rates. Studies were excluded if prescribing error rates could not be extracted, if HIT use was non-compulsory or designed for one class of medication. The Newcastle-Ottawa scale was used to assess study quality. The review was reported in accordance with the PRISMA and SWiM guidelines. Odds ratios (OR) with 95% confidence intervals (CI) were calculated across the studies. Descriptive statistics were used to summarise effect estimates. Two researchers examined studies for BCTs using a validated taxonomy. Effectiveness ratios (ER) were used to determine the potential impact of individual BCTs.

RESULTS

Thirty-five studies of variable risk of bias and limited intervention reporting were included. TGE were identified in 31 studies. Compared with paper-order entry, prescribing HIT of varying sophistication was associated with decreased rates of prescribing errors (median OR 0.24, IQR 0.03-0.57). Ten BCTs were present in at least two successful interventions and may be effective components of prescribing HIT implementation and optimisation including prescriber involvement in system design, clinical colleagues as trainers, modification of HIT in response to feedback, direct observation of prescriber workflow, monitoring of electronic orders to detect errors, and system alerts that prompt the prescriber.

CONCLUSIONS

Prescribing HIT is associated with a reduction in prescribing errors in a variety of hospital settings. Poor reporting of intervention delivery and content limited the BCT analysis. More detailed reporting may have identified additional effective intervention components. Effective BCTs may be considered in the design and development of prescribing HIT and in the reporting and evaluation of future studies in this area.

Interventions to reduce medication errors in adult medical and surgical settings: a systematic review

Background and Aims:

Medication errors occur at any point of the medication management process, and are a major cause of death and harm globally. The objective of this review was to compare the effectiveness of different interventions in reducing prescribing, dispensing and administration medication errors in acute medical and surgical settings.

Methods:

The protocol for this systematic review was registered in PROSPERO (CRD42019124587). The library databases, MEDLINE, CINAHL, EMBASE, PsycINFO, Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials were searched from inception to February 2019. Studies were included if they involved testing of an intervention aimed at reducing medication errors in adult, acute medical or surgical settings. Meta-analyses were performed to examine the effectiveness of intervention types.

Results:

A total of 34 articles were included with 12 intervention types identified. Meta-analysis showed that prescribing errors were reduced by pharmacist-led medication reconciliation, computerised medication reconciliation, pharmacist partnership, prescriber education, medication reconciliation by trained mentors and computerised physician order entry (CPOE) as single interventions. Medication administration errors were reduced by CPOE and the use of an automated drug distribution system as single interventions. Combined interventions were also found to be effective in reducing prescribing or administration medication errors. No interventions were found to reduce dispensing error rates. Most studies were conducted at single-site hospitals, with chart review being the most common method for collecting medication error data. Clinical significance of interventions was examined in 21 studies. Since many studies were conducted in a pre–post format, future studies should include a concurrent control group.

Conclusion:

The systematic review identified a number of single and combined intervention types that were effective in reducing medication errors, which clinicians and policymakers could consider for implementation in medical and surgical settings. New directions for future research should examine interdisciplinary collaborative approaches comprising physicians, pharmacists and nurses.

Lay summary

Activities to reduce medication errors in adult medical and surgical hospital areas

Introduction:

Medication errors or mistakes may happen at any time in hospital, and they are a major reason for death and harm around the world.

Objective:

To compare the effectiveness of different activities in reducing medication errors occurring with prescribing, giving and supplying medications in adult medical and surgical settings in hospital.

Methods:

Six library databases were examined from the time they were developed to February 2019. Studies were included if they involved testing of an activity aimed at reducing medication errors in adult medical and surgical settings in hospital. Statistical analysis was used to look at the success of different types of activities.

Results:

A total of 34 studies were included with 12 activity types identified. Statistical analysis showed that prescribing errors were reduced by pharmacists matching medications, computers matching medications, partnerships with pharmacists, prescriber education, medication matching by trained physicians, and computerised physician order entry (CPOE). Medication-giving errors were reduced by the use of CPOE and an automated medication distribution system. The combination of different activity types were also shown to be successful in reducing prescribing or medication-giving errors. No activities were found to be successful in reducing errors relating to supplying medications. Most studies were conducted at one hospital with reviewing patient charts being the most common way for collecting information about medication errors. In 21 out of 34 articles, researchers examined the effect of activity types on patient harm caused by medication errors. Many studies did not involve the use of a control group that does not receive the activity.

Conclusion:

A number of activity types were shown to be successful in reducing prescribing and medication-giving errors. New directions for future research should examine activities comprising health professionals working together.

Systematic review of computerized prescriber order entry and clinical decision support

PURPOSE

Results of a systematic review of published data on the effect of computerized prescriber order entry (CPOE) with clinical decision support on medication error (ME) and adverse drug event (ADE) rates are presented.

METHODS

Literature searches of MEDLINE, Embase, and other databases were conducted to identify English- and Spanish-language articles on selected CPOE outcomes published from 1995 through 2016; in addition, 5 specific journals were searched for pertinent articles published during the period 2010-16. Publications on controlled prospective studies and before-and-after studies that assessed MEs and/or ADEs as main outcomes were selected for inclusion in the review.

RESULTS

Nineteen studies met the inclusion criteria. Data on MEs and ADEs could not be pooled, mainly due to heterogeneity in outcome definitions and study methodologies. The reviewed evidence indicated that CPOE implementation led to an overall reduction in errors at the prescription stage of the medication-use process (relative risk reduction, 0.29 [95% confidence interval, 0.10-0.85]; I ² = 99%) and reductions in most types of prescription errors, but CPOE also resulted in the emergence of other types of errors.

CONCLUSION

CPOE reduces the overall ME rate in the prescription process, as well as specific types of errors, such as wrong dose or strength, wrong drug, frequency, administration route, and drug-drug interaction errors. The implementation of CPOE can lead to new errors, such as wrong drug selection from drop-down menus.

Comparative Cost-Effectiveness Analysis of Three Different Automated Medication Systems Implemented in a Danish Hospital Setting

INTRODUCTION

Automated medication systems have been found to reduce errors in the medication process, but little is known about the cost-effectiveness of such systems. The objective of this study was to perform a model-based indirect cost-effectiveness comparison of three different, real-world automated medication systems compared with current standard practice.

METHODS

The considered automated medication systems were a patient-specific automated medication system (psAMS), a non-patient-specific automated medication system (npsAMS), and a complex automated medication system (cAMS). The economic evaluation used original effect and cost data from prospective, controlled, before-and-after studies of medication systems implemented at a Danish hematological ward and an acute medical unit. Effectiveness was described as the proportion of clinical and procedural error opportunities that were associated with one or more errors. An error was defined as a deviation from the electronic prescription, from standard hospital policy, or from written procedures. The cost assessment was based on 6-month standardization of observed cost data. The model-based comparative cost-effectiveness analyses were conducted with system-specific assumptions of the effect size and costs in scenarios with consumptions of 15,000, 30,000, and 45,000 doses per 6-month period.

RESULTS

With 30,000 doses the cost-effectiveness model showed that the cost-effectiveness ratio expressed as the cost per avoided clinical error was €24 for the psAMS, €26 for the npsAMS, and €386 for the cAMS. Comparison of the cost-effectiveness of the three systems in relation to different valuations of an avoided error showed that the psAMS was the most cost-effective system regardless of error type or valuation.

CONCLUSION

The model-based indirect comparison against the conventional practice showed that psAMS and npsAMS were more cost-effective than the cAMS alternative, and that psAMS was more cost-effective than npsAMS.

The impact of computerized physician order entry on prescription orders: A quasi-experimental study in Iran

Background: One way to reduce medical errors associated with physician orders is computerized physician order entry (CPOE) software. This study was conducted to compare prescription orders between 2 groups before and after CPOE implementation in a hospital. Methods: We conducted a before-after prospective study in 2 intensive care unit (ICU) wards (as intervention and control wards) in the largest tertiary public hospital in South of Iran during 2014 and 2016. All prescription orders were validated by a clinical pharmacist and an ICU physician. The rates of ordering the errors in medical orders were compared before (manual ordering) and after implementation of the CPOE. A standard checklist was used for data collection. For the data analysis, SPSS Version 21, descriptive statistics, and analytical tests such as McNemar, chi-square, and logistic regression were used. Results: The CPOE significantly decreased 2 types of errors, illegible orders and lack of writing the drug form, in the intervention ward compared to the control ward (p< 0.05); however, the 2 errors increased due to the defect in the CPOE (p< 0.001). The use of CPOE decreased the prescription errors from 19% to 3% (p= 0.001), However, no differences were observed in the control ward (p<0.05). In addition, more errors occurred in the morning shift (p< 0.001). Conclusion: In general, the use of CPOE significantly reduced the prescription errors. Nonetheless, more caution should be exercised in the use of this system, and its deficiencies should be resolved. Furthermore, it is recommended that CPOE be used to improve the quality of delivered services in hospitals.

The Impact of Order Source Misattribution on Computerized Provider Order Entry (CPOE) Performance Metrics

BACKGROUND

One strategy to foster adoption of computerized provider order entry (CPOE) by physicians is the monthly distribution of a list identifying the number and use rate percentage of orders entered electronically versus on paper by each physician in the facility. Physicians care about CPOE use rate reports because they support the patient safety and quality improvement objectives of CPOE implementation. Certain physician groups are also motivated because they participate in contracted financial and performance arrangements that include incentive payments or financial penalties for meeting (or failing to meet) a specified CPOE use rate target. Misattribution of order sources can hinder accurate measurement of individual physician CPOE use and can thereby undermine providers' confidence in their reported performance, as well as their motivation to utilize CPOE. Misattribution of order sources also has significant patient safety, quality, and medicolegal implications.

OBJECTIVE

This analysis sought to evaluate the magnitude and sources of misattribution among hospitalists with high CPOE use and, if misattribution was found, to formulate strategies to prevent and reduce its recurrence, thereby ensuring the integrity and credibility of individual and facility CPOE use rate reporting.

METHODS

A detailed manual order source review and validation of all orders issued by one hospitalist group at a midsize community hospital was conducted for a one-month study period.

RESULTS

We found that a small but not dismissible percentage of orders issued by hospitalists-up to 4.18 percent (95 percent confidence interval, 3.84-4.56 percent) per month-were attributed inaccurately. Sources of misattribution by department or function were as follows: nursing, 42 percent; pharmacy, 38 percent; laboratory, 15 percent; unit clerk, 3 percent; and radiology, 2 percent. Order management and protocol were the most common correct order sources that were incorrectly attributed.

CONCLUSION

Order source misattribution can negatively affect reported provider CPOE use rates and should be investigated if providers perceive discrepancies between reported rates and their actual performance. Preventive education and communication efforts across departments can help prevent and reduce misattribution.

Impact of the introduction of electronic prescribing on staff perceptions of patient safety and organizational culture

BACKGROUND

Electronic prescribing (EP) systems are online technology platforms by which medicines can be prescribed, administered, and stock controlled. The actual impact of EP on patient safety is not truly understood. This study seeks to assess the impact of the implementation of an EP system on safety culture, as well as assessing differences between clinical respondent groups and considering their implications.

METHODS

Staff completed a modified Safety Attitudes Questionnaire survey, 6 weeks following the introduction of EP across surgical services in a hospital in Dorset, England. Responses were assessed and differences between respondent groups compared. Rates of self-reported adverse events were compared before and after implementation.

RESULTS

Overall response rate was 34.5%. There was no significant difference between usage patterns and previous experience with EP between user groups. Overall safety was felt to have been reduced by the introduction of EP. Significant differences between clinician and nonclinicians were seen in ability to discuss errors (3.23 ± 0.5 versus 2.8 ± 0.69, P = 0.004), drug chart access, and ease of medication prescribing. Regression analysis did not identify any confounding factors. Despite a significant reduction in the adverse event rate in other divisions of the hospital that did not implement EP at the same time, this same reduction was not seen in the surgical department.

CONCLUSIONS

This is the first study to assess the impact of EP on safety culture using a validated assessment tool (Safety Attitudes Questionnaire). Overall safety culture deteriorated following introduction of EP. Problems with system usability/intuitiveness, nonstandardized implementation, and competence assessment strategies may have all contributed to this result. Centers seeking to implement EP in future must consider these factors to ensure a positive impact on patient safety and outcomes.