Digital prescription systems miss potential drug errors

While dangerous drug errors are down significantly for hospitals that use digital medication orders, more than 10 percent of potentially fatal mistakes still slip through the cracks, according to a new report from the Leapfrog Group.

Medication mistakes comprise the lion's share of hospital medical errors. But the digital medication distribution systems that most hospitals use miss about 40 percent of potentially harmful orders and 13 percent of potentially lethal ones, the report found.  A study published last October found that at Massachusetts General Hospital, medication errors occurred in half of all surgeries over eight months, one third of which caused patient harm, FierceHealthcare previously reported.  

However, it's difficult to tell how many of the potential harms flagged actually caused tangible patient harm, Erica Mobley, Leapfrog's director of development and communications, told Kaiser Health News, since many hospitals have contingencies in place to catch potential errors even if their prescription systems don't alert them.

Regardless, the systems' fallibility means patients and hospital leaders must take steps to account for potential computer errors, such as ensuring patients have someone with them to confirm which drugs they are prescribed. "It's absolutely critical that whenever the patient or somebody with them notices that this maze [of medications] looks slightly different from what's been done in the past, they ask about that," Mobley told KHN.

Hospitals, meanwhile, must adapt and refine their software systems, adding capabilities such as discerning frequently ordered drugs. Since 2014, hospitals have only improved their potential error-flagging capabilities by about 1 percentage point, according to the report. Leapfrog calls for more drastic reforms, such as ensuring the hospital system catches at least half of all common and serious prescription errors and ordering at least three-quarters of inpatient medications through a computerized physician order entry (CPOE) system.

"For a lot of hospitals CPOE is new. When hospitals purchase a system it's not necessarily plug-and-play," Mobley told FierceHealthcare in an interview this morning. Hospitals must customize CPOE systems to adapt to both their existing systems and their specific patient populations, she said, "and so it's really important that hospitals take the time to customize these systems and to test them, and it may not be that all hospitals are doing that."

To learn more:
- download the report (.pdf)
- here's the KHN article