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Identifying and Quantifying Medication Errors: Evaluation of Rapidly Discontinued Medication Orders Submitted to a Computerized Physician Order Entry System

^a Department of Sociology, University of Pennsylvania, Philadelphia, PA
^b Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA
^c Center for Education and Research on Therapeutics, University of Pennsylvania School of Medicine, Philadelphia, PA
^d Department of Medicine (General Medicine Division), Department of Pharmacology, University of Pennsylvania School of Medicine, Philadelphia, PA.

^_* Correspondence: Ross Koppel, Ph.D. 813 Pardee Lane, Wyncote, PA 19095 (Email: rkoppel{at}sas.upenn.edu).

Received for publication: 07/06/07; accepted for publication: 03/19/08.

All methods of identifying medication prescribing errors are fraught with inaccuracies and systematic bias. A systematic, efficient, and inexpensive way of measuring and quantifying prescribing errors would be a useful step for reducing them.

We ask if rapid discontinuations of prescription-orders–where physicians stop their orders within 2 hours–would be an expedient proxy for prescribing errors?

To study this we analyzed CPOE-system medication orders entered and then discontinued within 2 hours. We investigated these phenomena in real time via interviews with corresponding ordering physicians. Each order was also independently reviewed by a clinical pharmacist or physicians. We found that of 114 rapidly discontinued orders by 75 physicians, two-thirds (35 of 53, PPV = 66; 95% CI = 53–77) of medication orders discontinued within 45 minutes were deemed inappropriate (overdose, underdose, etc.). Overall, 55% (63 of 114; 95% CI = 46–64%) of medication orders discontinued within 2 hours were deemed inappropriate.

This measure offers a rapid, constant, inexpensive, and objective method to identify medication orders with a high probability of error. It may also serve as a screening and teaching mechanism for physicians-in-training.