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PS-013 Errare humanum est, not only… a review of errors due to computerised physician order entry (CPOE)
  1. A Dericquebourg,
  2. M Watel,
  3. G Strobbe,
  4. G Marliot,
  5. I Sakji,
  6. S Delbey
  1. Oscar Lambret Center, Pharmacy, Lille, France

Abstract

Background Prescription computerization is an undeniable step forward in terms of safety. It can significantly reduce the errors associated with handwritten prescriptions. However these new practices are the source of new risks associated with interactions between humans and computers.

Purpose To identify and quantify these risks in our institution.

Material and methods We analysed the pharmaceutical interventions performed in DxCare software over a period of 15 months with the query tool Business Objects. We then ranked the interventions according to error types.

Results Over the study period, 48,551 prescription lines were analysed. 3,139 pharmaceutical interventions were performed (6.5% of prescription lines). Among these interventions, 971 (31%) were identified as related to computerization. The main errors identified were: prescription unit errors (n = 561), wrong administration procedures (n = 147), duplicate prescriptions (n = 143), wrong drug prescribed (n = 37), incomplete doses (n = 31), inappropriate use of software features (n = 29) and lastly, prescribed dose was inappropriate (n = 23). The root causes of these errors can be related to defects in software design, a lack of user training or a reluctance to use computers.

Conclusion Our analysis has highlighted that computer-related errors cannot and should not be overlooked. Optimising software and layout could reduce some of these errors. Other methods would require more in-depth training and a better understanding from the users. Finally, as patient safety is paramount, it is vital to see computerization as a tool for improvement and not as a quick fix.

Reference

  1. Charpiat B, Bedouch P, Conort O, et al. Opportunités d’erreurs médicamenteuses et interventions pharmaceutiques dans le cadre de la prescription informatisée: revue des données publiées par les pharmaciens hospitaliers français. Annales Pharmaceutiques Françaises 2012;70:62–74

ReferenceNo conflict of interest.

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