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September / October 2008
NEWS ITEMS FROM SOURCES WORLDWIDE
Pulse
Analysis of Quickly Stopped Rx
Orders Provides New Tool for
Reducing Medical Errors
Dr. Ross Koppel and colleagues at Penn's department of biostatistics and epidemiology used a hospital's computerized physician order entry (CPOE) system to track prescriptions that were discontinued within 45 minutes. They found the rate of errors among the quickly stopped orders was 66%. The Rx problem may have been detected by the ordering physician, another physician, a pharmacist, or a nurse, but the prescribing physician issues the stop order.
The University of Pennsylvania team examined each order stopped within a 2-hour time period, and when relevant, each subsequent order. Then they interviewed the prescribing physicians, asking about why they stopped the orders — looking at both who caught the error and the doctor's own explanation for the change. Often the reason for the change was obvious, e.g., a medication for the wrong eye or a dose that was far too large. Sometimes the reasons were more subtle, e.g., a more appropriate antibiotic. Koppel notes the classes of drugs most likely to be quickly discontinued made sense because they were often among the most difficult-to-prescribe: low therapeutic index drugs, insulin, antiretrovirals, antineoplastics, and immunosuppressive drugs.
Koppel (a sociologist by training) said that although they originally focused on the 2-hour period, they found that 45 minutes was the most efficient time cut for the measure. "Because this type of analysis is so new, we didn't know how long the post-ordering timeframe should be until we did it.
"Also, we did not count orders that were stopped within the first minute. That's so we didn't include typos and the kind of errors that would be the equivalent to tearing up a flawed paper prescription when writing it," Koppel said.
The researchers had a live transmission of every medication order as it was written and were able to interview the ordering physicians within hours, often within minutes. The team conducted the research over the course of 2 months, selecting times and days that reflected the physicians' ordering patterns at the hospital.
Currently, methods of identifying prescribing errors are plagued with inaccuracies stemming from several systematic biases. Self-report and reports by colleagues are known to substantially under-represent reality. Examining medical records misses errors linked to undocumented diagnoses, as well as being time-consuming and expensive. Other manifestations of medication error go unrecognized, write the authors, because symptoms are often complex, patients have multiple problems, and polypharmacy may obscure causes and outcomes. The paper identifies eight methods of detecting medication error and summarizes their shortcomings. Koppel added, "prescription errors are often obscured by the messy reality of illness, multi-faceted treatments, and the rapid pace and complexity of an acute care hospital"
The measure proposed here, while preliminary, indicates that 66% of prescriptions discontinued within 45 minutes after their origination are inappropriate. Even beyond the ratio comparisons, the value of this measure is several-fold: When linked to a CPOE system, it is rapid, constant (24/7), and does not depend on possibly biased evaluators, self-report, or others' reports. Data collection is also cost-free as part of a CPOE system.
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