Thursday, March 23, 2017

This Makes It Very Clear That Well Designed E-Prescribing Systems Are Vital To Preserve Patient Safety.

This appeared last week.

Poorly implemented IT systems lead to medication errors

Mar 17, 2017 10:58am
IT systems designed to streamline medication ordering and administration can contribute to medication errors.
Health IT systems designed to improve prescription ordering and medication administration can just as easily contribute to medical errors.
That’s according to a study released by the Pennsylvania Patient Safety Advisory (PPSA), which found that computerized prescriber order entry (CPOE) systems, pharmacy IT systems and electronic medication administration tools were frequently to blame for medication errors. Nearly 70% of those errors reached the patient.
Last year, researchers at Johns Hopkins published a study indicating that medical errors are the third-leading cause of death in the U.S., a study that drew harsh criticism from many physicians. Some have warned that digital prescription systems miss potential drug errors, and the Office of the National Coordinator for Health IT has called on vendors and providers to reduce the number of “pick list” medication errors.
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There is also coverage here:

Half of Medication Errors Involve CPOE, Data Shows

Alexandra Wilson Pecci, March 17, 2017

Computerized prescriber order entry systems and pharmacy systems are the most commonly reported factors contributing to medication errors in Pennsylvania healthcare facilities, data shows.

Although health IT tools can help prevent patient safety problems, they can also lead to significant patient safety errors if they're not used correctly, finds research from the Pennsylvania Patient Safety Authority.
Between January 1 and June 30, 2016, Pennsylvania healthcare facilities reported 889 medication-error events that indicated health IT as a contributing factor.
The most frequently reported errors included dose omission, wrong dose or overdosage, and extra dose. The most commonly reported systems involved in the errors were computerized prescriber order entry systems (CPOE) and the pharmacy systems.
"As more healthcare organizations adopted [EHR/EMRs (electronic health records systems)] and such systems became increasingly interoperable, the Authority observed an increase in reports of HIT-related events, particularly in relationship to medication errors.
In response, the Authority implemented additional event reporting questions that would better capture whether HIT was a contributing factor in reported events," the Authority's executive director,Regina Hoffman, said in a statement accompanying the report.
In 2015, a new question was added to the Pennsylvania Patient Safety Reporting System (PA-PSRS) reporting form: "Did Health IT cause or contribute to this event?" opening a topic that had not been explored before, it says.
PA-PSRS is a web-based system that a secure, web-based system where healthcare facilities, including hospitals, ambulatory surgical facilities, and birthing centers, are required to submit reports of "serious events" and "incidents."
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Clearly any medication management program needs to start with sorting these sorts of findings out and getting the error rates to as close to zero as possible!

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