Examining medication ordering errors using AHRQ network of patient safety databases
© The Author(s) 2023. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissionsoup.com..
BACKGROUND: Studies examining the effects of computerized order entry (CPOE) on medication ordering errors demonstrate that CPOE does not consistently prevent these errors as intended. We used the Agency for Healthcare Research and Quality (AHRQ) Network of Patient Safety Databases (NPSD) to investigate the frequency and degree of harm of reported events that occurred at the ordering stage, characterized by error type.
MATERIALS AND METHODS: This was a retrospective observational study of safety events reported by healthcare systems in participating patient safety organizations from 6/2010 through 12/2020. All medication and other substance ordering errors reported to NPSD via common format v1.2 between 6/2010 through 12/2020 were analyzed. We aggregated and categorized the frequency of reported medication ordering errors by error type, degree of harm, and demographic characteristics.
RESULTS: A total of 12 830 errors were reported during the study period. Incorrect dose accounted for 3812 errors (29.7%), followed by incorrect medication 2086 (16.3%), and incorrect duration 765 (6.0%). Of 5282 events that reached the patient and had a known level of severity, 12 resulted in death, 4 resulted in severe harm, 45 resulted in moderate harm, 341 resulted in mild harm, and 4880 resulted in no harm.
CONCLUSION: Incorrect dose and incorrect drug orders were the most commonly reported and harmful types of medication ordering errors. Future studies should aim to develop and test interventions focused on CPOE to prevent medication ordering errors, prioritizing wrong-dose and wrong-drug errors.
| Medienart: |
E-Artikel |
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| Erscheinungsjahr: |
2023 |
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| Erschienen: |
2023 |
| Enthalten in: |
Zur Gesamtaufnahme - volume:30 |
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| Enthalten in: |
Journal of the American Medical Informatics Association : JAMIA - 30(2023), 5 vom: 19. Apr., Seite 838-845 |
| Sprache: |
Englisch |
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| Beteiligte Personen: |
Grauer, Anne [VerfasserIn] |
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| Links: |
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| Themen: |
Computerized provider order entry (CPOE) |
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| Anmerkungen: |
Date Completed 20.04.2023 Date Revised 10.02.2024 published: Print Citation Status MEDLINE |
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| doi: |
10.1093/jamia/ocad007 |
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| funding: |
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| Förderinstitution / Projekttitel: |
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| 520 | |a © The Author(s) 2023. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissionsoup.com. | ||
| 520 | |a BACKGROUND: Studies examining the effects of computerized order entry (CPOE) on medication ordering errors demonstrate that CPOE does not consistently prevent these errors as intended. We used the Agency for Healthcare Research and Quality (AHRQ) Network of Patient Safety Databases (NPSD) to investigate the frequency and degree of harm of reported events that occurred at the ordering stage, characterized by error type | ||
| 520 | |a MATERIALS AND METHODS: This was a retrospective observational study of safety events reported by healthcare systems in participating patient safety organizations from 6/2010 through 12/2020. All medication and other substance ordering errors reported to NPSD via common format v1.2 between 6/2010 through 12/2020 were analyzed. We aggregated and categorized the frequency of reported medication ordering errors by error type, degree of harm, and demographic characteristics | ||
| 520 | |a RESULTS: A total of 12 830 errors were reported during the study period. Incorrect dose accounted for 3812 errors (29.7%), followed by incorrect medication 2086 (16.3%), and incorrect duration 765 (6.0%). Of 5282 events that reached the patient and had a known level of severity, 12 resulted in death, 4 resulted in severe harm, 45 resulted in moderate harm, 341 resulted in mild harm, and 4880 resulted in no harm | ||
| 520 | |a CONCLUSION: Incorrect dose and incorrect drug orders were the most commonly reported and harmful types of medication ordering errors. Future studies should aim to develop and test interventions focused on CPOE to prevent medication ordering errors, prioritizing wrong-dose and wrong-drug errors | ||
| 650 | 4 | |a Observational Study | |
| 650 | 4 | |a Journal Article | |
| 650 | 4 | |a Research Support, U.S. Gov't, P.H.S. | |
| 650 | 4 | |a computerized provider order entry (CPOE) | |
| 650 | 4 | |a ordering errors | |
| 650 | 4 | |a patient safety | |
| 700 | 1 | |a Rosen, Amanda |e verfasserin |4 aut | |
| 700 | 1 | |a Applebaum, Jo R |e verfasserin |4 aut | |
| 700 | 1 | |a Carter, Danielle |e verfasserin |4 aut | |
| 700 | 1 | |a Reddy, Pooja |e verfasserin |4 aut | |
| 700 | 1 | |a Dal Col, Alexis |e verfasserin |4 aut | |
| 700 | 1 | |a Kumaraiah, Deepa |e verfasserin |4 aut | |
| 700 | 1 | |a Barchi, Daniel J |e verfasserin |4 aut | |
| 700 | 1 | |a Classen, David C |e verfasserin |4 aut | |
| 700 | 1 | |a Adelman, Jason S |e verfasserin |4 aut | |
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