PEDIATRICS Vol. 119 No. 1 January 2007, pp. e77-e85 (doi:10.1542/peds.2006-0034)
ARTICLE |
Prevention of Pediatric Medication Errors by Hospital Pharmacists and the Potential Benefit of Computerized Physician Order Entry
a Cedars-Sinai Health System, Los Angeles, California
b David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
c Weill Medical College of Cornell University, New York, New York
d Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
e Northeast Valley Health Corporation, San Fernando, California
f Zynx Health Incorporated, Los Angeles, California
OBJECTIVES. The purpose of this work was to characterize medication errors and adverse drug events intercepted by a system of pediatric clinical pharmacists and to determine whether the addition of a computerized physician order entry system would improve medication safety.
METHODS. The study included 16938 medication orders for 678 admissions to the pediatric units of a large academic community hospital. Pediatric clinical pharmacists reviewed medication orders and monitored subsequent medication use. Medication errors and adverse drug events were identified by daily review of documentation, voluntary reporting, and solicitation. Each potentially harmful medication error was judged whether or not it was intercepted and, if not, whether it would have been captured by a computerized physician order entry system.
RESULTS. Overall, 865 medication errors occurred, corresponding with a rate of 5.2 per 100 medication orders. A near-miss rate of 0.96% and a preventable adverse drug event rate of 0.09% were observed. Overall, 78% of potentially harmful prescribing errors were intercepted; however, none of the potentially harmful errors occurring at administration was intercepted and accounted for 50% of preventable adverse drug events. A computerized physician order entry system could capture additional potentially harmful prescribing and transcription errors (54%–73%) but not administration errors (0% vs 6%).
CONCLUSIONS. A system of pediatric clinical pharmacists effectively intercepted inpatient prescribing errors but did not capture potentially harmful medication administration errors. The addition of a computerized physician order entry system to pharmacists is unlikely to prevent administration errors, which pose the highest risk of patient injury.
Key Words: pediatrics • medication errors • adverse drug events • hospital pharmacy services • computerized physician order entry • CPOE
Abbreviations: ADE—adverse drug event • CPOE—computerized physician order entry • CI—confidence interval
Accepted Aug 9, 2006.
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