Technology to Prevent Medication Errors Still Fails Too Often, Study Finds

While a record number of hospitals are adopting computerized physician order entry (CPOE) systems, which can substantially reduce common medication errors, there is still work to do, according to a new report from The Leapfrog Group.

A record-high 1339 hospitals in the US reported using a CPOE system in at least one inpatient unit, this is up 248% from just 384 in 2010. More than half (59%) of hospitals using CPOE reported using it to enter at least 75% of inpatient medication orders.

“Because approximately 90% of medication errors occur during manual ordering and transcribing (writing and interpreting the prescription), the use of CPOE systems could help eliminate these types of errors,” the authors of the report wrote.

While the proportion of potentially harmful orders that did not receive an appropriate warning remained at 36%, the number of potentially fatal orders that were flagged fell from 15.2% in 2013 to 13.9%, according to the report. This data came from Leapfrog’s CPOE Evaluation Tool, which tests whether or not a CPOE system is alerting physicians to common, serious prescribing errors, such as drug-to-drug interactions and drug-allergy interactions. In 2014, hospitals performed 1249 tests of their CPOE systems using Leapfrog’s tool.

Errors such as incorrect dosing, mislabeled drug allergies, and harmful drug interactions are not only frequent and potentially fatal, but they cost approximately $4300 per error, according to Leapfrog.

“Effective use of CPOE systems can help reduce the risk of a wrong drug or dose being delivered to a patient, and avert problems caused by poor handwriting, similar drug names, drug interactions and specification errors,” the authors wrote. “Any of these types of mistakes can lead to serious consequences for patients, from not receiving the benefit of the intended medication to death from a severe allergic reaction.”

This report is part of a series from Leapfrog and Castlight Health. A previous report found that survival rates for high-risk surgical procedures can vary significantly hospital-to-hospital.