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Technology-induced errors associated with computerized provider order entry software for older patients

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Abstract

Background The introduction of new technologies in the prescribing process has seen the emergence of new types of medication errors. Objective To determine the prevalence and consequences of technology-induced prescription errors associated with a computerized provider order entry (CPOE) system in hospitalized older patients. Setting Patients 65 years or older admitted to the Departments of Internal Medicine, General Surgery, and Vascular Surgery of a tertiary hospital. Method Prospective observational 6-month study. Technology-induced errors were classified according to various taxonomies. Interrater reliability was measured. Consequences were assessed by interviewing patients and healthcare providers and classified according to their severity. Main outcome measure Prevalence of technology-induced errors. Results A total of 117 patients were included and 107 technology-induced errors were recorded. The prevalence of these errors was 3.65%. Half of the errors were clinical errors (n = 54) and the majority of these were classified as wrong dose, wrong strength, or wrong formulation. Clinical errors were 9 times more likely to be more severe than procedural errors (14.8 vs 1.9%; OR 9.04, 95% CI 1.09–75.07). Most of the errors did not reach the patient. Almost all errors were related to human–machine interactions due to wrong (n = 61) or partial (n = 41) entries. Conclusion Technology-induced errors are common and intrinsic to the implementation of new technologies such as CPOE. The majority of errors appear to be related to human–machine interactions and are of low severity. Prospective trials should be conducted to analyse in detail the way these errors occur and to establish strategies to solve them and increase patient safety.

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Authors and Affiliations

  1. Pharmacy Department, Hospital Universitario Ramón y Cajal, Carretera de Colmenar km 9, 1, Madrid, 28034, Spain

    Manuel Vélez-Díaz-Pallarés, Ana María Álvarez Díaz, Teresa Gramage Caro, Noelia Vicente Oliveros, Eva Delgado-Silveira, María Muñoz García, Alfonso José Cruz-Jentoft & Teresa Bermejo-Vicedo

  2. Servicio de Geriatría, Hospital Universitario Ramón y Cajal (IRYCIS), Madrid, Spain

    Alfonso José Cruz-Jentoft

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  1. Manuel Vélez-Díaz-Pallarés
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Correspondence to Manuel Vélez-Díaz-Pallarés.

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Manuel Vélez-Díaz-Pallarés, Ana María Álvarez Díaz, Teresa Gramage Caro, Noelia Vicente Oliveros, Eva Delgado Silveira, María Muñoz García, Alfonso José Cruz-Jentoft, and Teresa Bermejo-Vicedo declare that they have no conflict of interest.

Appendix

Appendix

Class D errors (An error occurred that reached the patient and required monitoring to confirm that it resulted in no harm to the patient and/or required intervention to preclude harm)

Clinicians prescribed oral acenocoumarol 1 mg for a patient with atrial fibrillation. In the observations free-text field the clinicians specified “alternating 0.5 and 1 mg”. However, nurses administered 1 mg for several days continuously and INR increased to 3.36 (optimal range for the patient was 2–3). The patient did not experience any bleeding and no antidotes were required.

Classic taxonomy: Unclear order

Technology-induced error taxonomy: Wrong entry

At home, a patient was regularly taking zolpidem 5 mg for a sleeping disorder. The hospital formulary only includes zolpidem 10-mg tablets. From the drop-down menu, the clinician chose this option without noticing the difference in dosage. The patient experienced delirium the following day, but it is likely that the delirium was due to an underlying acute kidney lesion. No causal relationship was established between the event and the high dose of zolpidem.

Classic taxonomy: Wrong dose

Technology-induced error taxonomy: Wrong entry

At home, a patient was taking half a tablet of spironolactone 25 mg/d to treat fluid retention secondary to congestive heart failure. During hospitalization, for no apparent reason, the clinician increased the dose of spironolactone to 50 mg/d. When the doctor chose the 50-mg dose from the drop-down menu, the software autocompleted the normal posology (1-0-0) and the physician failed to check the dose. The patient received spironolactone 50 mg for a few days and experienced hyperkalemia (5.3 mEq/L) on the last day of hospitalization. The attending team did not perform any interventions. At discharge, the dose of spironolactone was corrected to the dose that the patient was taking at home prior to hospitalization.

Classic taxonomy: Wrong dose

Technology-induced error taxonomy: Wrong entry

At home, the same patient was taking candesartan 8 mg/d for hypertension. The hospital formulary only includes candesartan 4 and 16 mg. In the drop-down menu, the physician selected the 16-mg dose, which is first one to appear on the menu, and prescribed the whole tablet to the patient. After selecting the dose from the drop-down menu, the physician failed to verify the dose that the patient was taking previously. The patient received a high dose of 16 mg candesartan for a few days and experienced hyperkalemia (5.3 mEq/L) on the last day of hospitalization. Again, the attending team did not perform any interventions. At discharge, the dose of candesartan was corrected to 8 mg/d.

Classic taxonomy: Wrong dose

Technology-induced error taxonomy: Wrong entry

During hospitalization, a patient was taking acenocoumarol for atrial fibrillation. The clinician prescribed variable doses of acenocoumarol for 1 week and introduced 2 prescription lines as if he was prescribing 2 drugs. In one line, the physician prescribed acenocoumarol 1 mg every 2 days with dinner. In the other line, he prescribed acenocoumarol 2 mg every 2 days with lunch. The abbreviations of the 2 eating periods are similar in the Spanish software (CE for dinner vs CO for lunch). When the physician printed the administration chart (in which nurses sign the administrations) he failed to note that this would cause confusion and also did not explain the 2 different prescriptions to the nurses. However, due to the 2 different timepoints of prescription (lunch and dinner), the nurses made the assumption to administer acenocoumarol 2 mg at lunch and 1 mg at dinner; no acenocoumarol was given the following day. As acenocoumarol 3 mg was given on the same day, the INR level increased to 4.58. The patient experienced no bleeding. There were no interventions.

Classic taxonomy: Wrong frequency

Technology-induced error taxonomy: Wrong entry

Class E errors (An error occurred that may have contributed to or resulted in temporary harm to the patient and required intervention)

At home, a patient was taking half a tablet of trazodone 100 mg at night for depression. In hospital, the physician introduced her domiciliary treatment into the CPOE software. The software autocompleted the dose of 100 mg and the physician validated the order. The new high dose of trazodone increased sleepiness in the patient. The patient family members noticed this effect and complained to the nurse.

Classic taxonomy: Wrong dose

Technology-induced error taxonomy: Wrong entry

During hospitalization, a patient experienced neuropathic pain and the clinicians prescribed pregabalin. The junior physician wanted to start with the minimal dose because the patient was a fragile woman. A range of doses of pregabalin are available in the hospital formulary. When prescribed in the CPOE software, pregabalin 150, 25, and 75 mg are displayed in the drop-down menu. The physician chose the 150-mg dose, which is the first to appear in the drop-down menu. The nurse administered a pregabalin 150-mg capsule to the patient. The patient fell asleep for 15 h. The family had to call the duty doctor, who ordered close monitorization of her vital signs.

Classic taxonomy: Wrong dose

Technology-induced error taxonomy: Wrong entry

A patient experienced atrial fibrillation and hypertension. At home, she was taking time-release diltiazem 180 mg twice daily. During admission, the physician wanted to prescribe the same treatment but erroneously chose time-release diltiazem 120 mg twice a day from the drop-down menu of the electronic prescription software. After 3 days (there was an intervening weekend), the patient experienced tachycardia and the physician realized that the dose prescribed was subtherapeutic. The prescription was immediately changed to time-release diltiazem 180 mg twice a day; however, digoxin had to be started to restore sinus rhythm. Subsequently, the patient experienced digoxin intoxication and the drug had to be stopped. The patient underwent complete recovery.

Classic taxonomy: Wrong dose

Technology-induced error taxonomy: Wrong entry

At home, a patient was taking clomethiazole as a short-acting hypnotic once a day at night. When the physician entered this treatment in the pharmacy prescription software, the internal rules autocompleted the normal posology of clomethiazole to 3 times a day (the normal posology to treat alcohol withdrawal). The patient received these new doses just for 1 day but developed somnolence. The nurse had to intervene and withdrew the doses given at breakfast and lunch on the following day. The physician changed the prescription on day 2.

Classic taxonomy: Wrong frequency/dose

Technology-induced error taxonomy: Wrong entry

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Vélez-Díaz-Pallarés, M., Álvarez Díaz, A.M., Gramage Caro, T. et al. Technology-induced errors associated with computerized provider order entry software for older patients. Int J Clin Pharm 39, 729–742 (2017). https://doi.org/10.1007/s11096-017-0474-y

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