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First published April 24, 2008 as JAMIA PrePrint; doi:10.1197/jamia.M2549
Journal of the American Medical Informatics Association 2008;15(4):461-465
© 2008 American Medical Informatics Association

A more recent version of this article appeared on July 1, 2008
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Submitted on July 6, 2007
Accepted on March 19, 2008

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

Ross Koppel PhD1*, Charles E. Leonard PharmD2, A. Russell Localio JD, PhD2, Abigail Cohen PhD2, Ruthann Auten BS2, and Brian L. Strom MD, MPH3

Affiliation of the authors: 1 Department of Sociology, University of Pennsylvania, Philadelphia, PA; Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA ; 2 Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA; Center for Education and Research on Therapeutics, University of Pennsylvania School of Medicine, Philadelphia, PA ; 3 Department of Medicine (General Medicine Division), University of Pennsylvania, Philadelphia, PA; Department of Pharmacology, University of Pennsylvania, Philadelphia, PA; Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA; Center for Education and Research on Therapeutics, University of Pennsylvania, Philadelphia, PA

* To whom correspondence should be addressed.

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 a rapid discontinuation 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 them in real time via interviews with their ordering-physicians. Each order was also independently reviewed by 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.






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