Medication Errors Go Under Microscope

The Center for Patient Safety Research and Practice recently received a $100,000 to take a hard look at errors associated with computerized physician order entry systems and assess the vulnerability of leading CPOE systems. But the project will only reveal part of the overall situation with medication errors.

"What we're going to be doing is tapping into data that's been collected on medication errors and trying to learn, particularly, about CPOE-associated errors," said Gordon Schiff, M.D., principal investigator of the project and associate director of the Center for Patient Safety Research and Practice at the Brigham and Women's Hospital in Boston, which received the research grant from the National Patient Safety Foundation.

Quantros, the company that manages Medmarx, a Web-based tool that collects anonymous reports of medication errors in a database, will partner with the patient safety center on the yearlong project. Quantros is also partnering with the Institute for Safe Medication Practices to help support project reporting and analysis.

"This database will provide only a piece of the larger puzzle for sure," said Schiff. Medmarx is a voluntary reporting system that a limited number of hospitals subscribe to, Schiff said. He estimated many hundreds of other hospitals report to other databases, while some don't report at all.

"I don't think we can use this in any way to judge the overall number of CPOE errors," he said. Also, he said, some of the reports classified as CPOE-related may not bear up to that designation upon closer examination.

Researchers from the Center for Patient Safety Research and the Quantros Patient Safety Center, a federally certified Patient Safety Organization, will investigate about 200,000 Medmarx records where CPOE was listed as a contributing factor. The research will focus on topics such as:

Creating descriptive statistics to analyze the drugs, dosing issues, prescribing and dispensing issues, outcomes and other contributing factors identified by people who report CPOE-related errors Extracting insights from report narratives to better understand the nature and mechanism of reported CPOE-related errors and how better designed systems might prevent them, and Developing and testing a new classification of CPOE-related errors and process failure modes to collect more useful data Schiff said CPOE has been cited as a contributing factor in medical errors with greater frequency. "It was becoming the third or fourth most common contributing factor in their annual reports each year," he said. The study will focus on the most serious error reports, or those where harm was inflicted on the patient, he said. "First we'll look at a few thousand of the high-harm reports and go through those in detail, reviewing the narrative." Schiff will have three research pharmacists working with him, leveraging qualitative research tools with the goal of possibly identifying new taxonomies of computer-related medication errors. "We want to hear what people on ground are trying to tell us in these reports," he said. "People took the time and trouble to write up these reports, and many are quite detailed. If they took time to submit them, we owe it to the reporters and the patients who experienced adverse effects to really dive in and learn everything we can from them. From studying each report and aggregating information across reports, we hope to find things that hopefully could be preventable with redesigned systems or processes."

Anthony Guerra is the founder and editor of healthsystemCIO.com, a site dedicated to serving the strategic information needs of healthcare CIOs. He can be reached at [email protected]. Read our new report on how IP telephony is being used in healthcare settings. Download the report now (registration required).