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PS-061 Computerised physician order entry: New risks identified by hospital pharmacists
  1. A Cyrus1,
  2. M Marchand1,
  3. L Estrade1,
  4. P Massip1,
  5. P Cestac1,
  6. S Pomies2,
  7. J Jouglen2,
  8. B Juillard-Condat1
  1. 1CHU de Toulouse, Comedims, Toulouse, France
  2. 2CHU de Toulouse, Pharmacy, Toulouse, France

Abstract

Background Computerisation helps secure the drug supply chain but generates new risks of errors, especially at the time of prescribing. When analysing prescriptions, the pharmacist can catch errors in order to avoid adverse drug events. In the hospital, the computerised physician order entry (CPOE) system ORBIS has being deployed since 2012. Currently, 1503 beds are computerised (50% of the hospital beds).

Purpose To analyse pharmaceutical interventions in a university hospital over a 10 month period in order to understand what the most common errors related to computerisation are and how to prevent them.

Material and methods In the hospital, each pharmaceutical intervention is categorised according to the French Society of Clinical Pharmacy (SFPC) tool. All pharmaceutical interventions over the past 10 months were extracted from the CPOE system of the hospital. Those errors related to computer tools were analysed and categorised into homogeneous groups.

Results Of the 3639 pharmaceutical interventions, 401 (11%) related to an error from the supply chain computerisation. The most common anomaly (38% of interventions) was duplication of therapeutic lines. An incorrect unit prescription, leading to aberrant dosage, accounted for 36% of cases. Improper treatment planning (starting time or lack of stopping treatment) caused 10% of interventions. Other causes of errors were marginal: prescription of a drug out of the drug formulary (5%), improper configuration of a product sheet or a prescription protocol (3%), inappropriate comments (1%) and lack of prescribing of the drug intake autonomy (1%).

Conclusion Errors generated by the use of a CPOE system can cause serious damage if they are not detected prior to administration to the patient: duplication of a therapeutic line or a unit error can lead to an overdose. The pharmacist’s role is not only to intercept these errors during the pharmaceutical analysis, but also to anticipate them working upstream on configuring the CPOE system so that it facilitates prescriptions and avoids mistakes. In addition, CPOE e-learning has been created in order to mitigate the risk of errors when prescribing.

No conflict of interest.

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