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Computerized medication data may be cause for concern

Nurse Leader Weekly, December 30, 2004

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The United States Pharmacopeia (USP) says nearly 20% of hospital and health system medication errors reported to its MEDMARX program in 2003 were the result of computerization or automation errors.

Computer entry (CE) errors were the fourth leading cause of medication errors last year according to MEDMARX data. Computer entry errors occur when incorrect or incomplete information is entered into a computer system-such as patient names, drug doses, or laboratory test results..According to USP's data, most CE errors occurred in either the transcribing/documenting phase or dispensing phase of the medication use process.

CE errors have steadily increased and represent 11.5% of all MEDMARX records from 1999-2003. The data indicate that nearly three-quarters of all CE errors occur after an order is written but before the medication is administrated to the patient.

Other significant findings associated with CE errors:

* "Performance deficit" was the most frequently reported cause of error. (A performance deficit is a cause of error in which the healthcare practitioner has the required skills and knowledge to execute a task but errs nonetheless.) 
* Distractions were the leading contributing factor, accounting for 56.5 % of errors.
* Wrong dose errors occurred more frequently in CE records compared to overall 2003 data, indicating that there was a higher occurrence of selecting the incorrect dose when a computer entry system was involved in processing the drug order after it was written.

These findings are part of USP's annual report which was released on December 21 and provides a comprehensive analysis of about 235,000 medication error records voluntarily reported by 570 hospitals and healthcare facilities nationwide.

Source: USP

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