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PS-084 New errors associated with computerised physician order entry system: incorrect medication schedule
  1. JA Dominguez Menendez,
  2. N Pardo Santos,
  3. S Vallinas Hidalgo,
  4. I Loizaga Díaz,
  5. LM Mendarte Barrenechea,
  6. MJ Yurrebaso Ibarreche
  1. Basurto Hospital, Pharmacy, Bilbao, Spain


Background The introduction of a computerised physician order entry (CPOE) system in 2010 changed the way of working in our hospital. Previously, the administration of medicines was scheduled by nurses, whereas now it is set in advance by physicians. Medicines administration can be delayed or omitted if nurses are unaware of CPOE timetables fixed in advance.

Purpose To quantify and analyse medication errors associated with incorrectly scheduled prescriptions.

Material and methods Retrospective observational study of a 10-day period. To facilitate the study only one daily medicine regimen was selected (levofloxacin). Started or modified treatments (sequential treatment, treatment or timetable change), and their administration records were reviewed the day after. Omission was considered if the medicine was not administered in a 24 h period, and incorrect prescription if the pre-arranged timetable was 8 h later than that stated in the prescription or if a dose was repeated in the day.

Results 20 levofloxacin start treatments and 48 modifications were collected (47 oral and 21 intravenous). Classified by Service: 18 Respiratory (RES), 16 Internal Medicine (IMD), 16 Emergencies (E), 13 Cardiology (CAR), 5 others.

9 omissions (13%) and 6 duplicated doses (9%) were detected. 5 errors occurred on starting and 10 during sequential treatment. Classified by Service: E, 3 omissions and 2 duplications (31%); IMD, 3 omissions and 2 duplications (31%); CAR, 2 omissions and 1 duplication (23%); Others, 1 omission (20%); RES, 1 duplication (5%). Incorrect prescription (35%) was the cause in all errors that occurred.

Conclusion CPOE systems reduce potential errors associated with medication. However, these systems can be a source of new errors if they are used incorrectly. To prevent these errors a system of continuing CPOE training is necessary for physicians. Due to the results, the Pharmacy Service informed all physicians about correctly scheduling medication, giving examples.

References and/or acknowledgements No conflict of interest.

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