News Corner: Lack of Initiative Minimizes Ability to Catch Medication Errors

A significant amount of time and money is spent in hospitals each year to implement technology to reduce medication errors and improve patient safety. However, if the technology is not fully functional, facilities may not be benefiting as they had hoped.

CPOE Programs

One example is the use of computerized physician order entry (CPOE) programs.

Currently, 97% of hospitals are using a CPOE system to handle medication ordering and keep records. Although these programs catch nearly 9 in 10 possible errors, many lack safeguards which would lessen the risk of medication errors, such as the ability to stop doctors from copying information from one chart to another or committing fraud. In fact, according to a recent study by Leapfrog Group, CPOE systems lack the programming needed to catch almost 40% of the most commonly made errors.

More Follow-through Needed

Perhaps the most disturbing piece learned from the Leapfrog survey was the lack of initiative in ensuring these systems were fully implemented, meaning they alert doctors about harmful drug errors. The Leapfrog Group invited all adult general acute-care and free-standing pediatric hospitals to participate in the study, but of all the hospitals invited, over half declined participation. Of those that did participate, approximately one-third didn’t fully meet Leapfrog’s CPOE standards—place at least 75% of inpatient orders through the system and show that the system catches at least 50% of the serious and common prescribing errors.

Maine, Georgia, and New York were the top scoring states in terms of meeting safeguard standards–coming in above 80%. However, even with safeguards, many cases of unflagged or non-alerted errors were recorded. Knowing this, it is clear that additional steps need to be taken to improve the accuracy of these programs and minimize the margin for error.

Above all, hospitals need to ensure that all of the safeguards their system provides are fully functional and that their physicians are using CPOE whenever inpatient medication orders are placed. With CPOE systems failing to flag 13% of potentially fatal orders, facilities must do what they can to maximize all that the systems have to offer.

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