Running head: PREVENTING MEDICATION ERRORS IN THE HOSPITAL 1

Preventing Medication Errors in the Hospital

Ashley Joseph

University of South Florida

PREVENTING MEDICATION ERRORS IN THE HOSPITAL 2

Abstract

Clinical problem: since health care providers treat multiple patients each day with

numerous medications, it is easy for medication errors to occur; medication errors can have

serious health effects on the patient and financial effects on the hospital. The objective of this

paper is to determine if technological improvements in the hospital can reduce the incidence of

medication errors. The technological improvement that is focused on is computerized physician

order medication entries. Scholar Google was utilized to search for studies on this topic, and a

few online journals were used. Some key search terms include medication errors, preventing

medication errors in the hospital, and technology used to prevent medication errors. The results

of the various journals stated that computerized physician order medication entries generally

minimize the occurrence of medication errors in the hospital setting. A study by Bates revealed

that medication errors dropped by about 81% when they were computer physician order

medication entries. This is a tremendously substantial decrease. However, according to Koppel’s

study, medication errors can still occur if the wrong patient or wrong dose is selected by the

healthcare provider. So even though this technology can be very helpful with preventing

medication errors, nurses still need to verify information themselves to protect the patient. In

conclusion, using technology in hospitals is greatly beneficial to both the hospital and the

patients. Computerized physician order medication entries, or CPOEs, help significantly reduce

the amount of medication errors. This helps bring down the financial burden on the hospital and

it protects the patients’ wellbeing. It also prevents the hospital from receiving a ruinous

reputation for causing harm to patients. Every hospital should always utilize CPOEs.
PREVENTING MEDICATION ERRORS IN THE HOSPITAL 3

Preventing Medication Errors in the Hospital

In the hospital setting, it can get very hectic taking care for multiple patients with various

illnesses or problems. The entire healthcare team must work together to provide the best care and

treatment for each patient, but it can be easy to get lost in the millions of patients and their many

medications. Of course, everyone from the physicians to the nurses to the patient care techs get

extremely busy and may shout different orders at each other while identifying the patient by the

room number. This can get confusing, especially with hospital rooms occupied by two patients.

Luckily, technology has greatly improved communication and efficiency in the hospitals.

However, medication errors still occur. Fayaz-Bakhsk has stated that although most medication

errors do not cause too much harm to the patient, they add onto the heavy workload that the

hospital staff must already deal with. Sadly, these medication errors are relatively common in the

chaos of hospitals. Some of these errors, according to Fayaz-Bakhsk can cause injury or life-

threatening situations that could have been prevented. Although these errors may only cost time,

they may cost a life.

Two background questions include the following: Is communication between healthcare

providers one of the reasons why there are medication errors, especially in the medical-surgical

units? How is technology helping to decrease the amount of medication errors that occur in the

hospital setting? An evidenced-based practice question for this topic is the following: In medical-

surgical unit patients with multiple medications (P), how does computerized physician order

medication entries (I), compared with physician medication verbal orders (C), affect the amount

of medication errors that occur (O), during each shift (T)? The expected outcome is little to no

medication errors for each patient during the length of their entire hospital stay.

Literature Search
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Through the Scholar Google database, three journals were accessed and utilized

for this paper. Two of the journals were retrieved Scholar Google which lead to Jama, which is a

peer-reviewed medical journal that is published by the American Medical Association. The last

journal was retrieved from the International Journal of Clinical Pharmacy. Both sources are

reputable for medication.

Literature Review

For the first RCT, the study was a comparison study that compared six medical surgical

units and followed the patients in a stratified random sample for six months, and then continued

another nine months. This study took place in a tertiary hospital. The intervention was using

CPOEs and a team-based intervention, and the outcome to be measured was nonintercepted

serious medication errors. The conclusion was that physician computer ordered entries cut down

the rate of serious medication errors by more than fifty percent according to this study conducted

by Bates. This is very significant, because adverse drug effects, ADEs, from medication errors

are very costly for both patients and the hospital. According to Bates, ADEs caused about 19%

of injuries in patients, and they are also very costly to the health care system. Bates has found

that ADEs have been costing hospitals $2 billion annually throughout the nation, and this does

not include malpractice costs (Bates, 1998). If the ADE causes hospitalization, it can be just as

expensive. These costs and injuries are greatly decreased by having physicians input their

medication orders onto the computer instead of giving the orders verbally to nurses who might

make the mistake of getting numbers mixed up, and it can prevent physicians from ordering the

wrong medication to the wrong patient by getting room numbers mixed up.

A second study that discusses physician order entry and their role on preventing

medication errors was done by Koppel. In this study, qualitative and quantitative data were
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collected. This study observed nurses using computerized physician order entries and it also

conducted five focus groups and 32 one-on-one interviews to determine if computerized

physician order entries are causing medication errors. It has found that computerized physician

order entries have decreased the amount of medication errors compared to orders that are

handwritten. There are multiple reasons for this. According to Koppel and the study,

computerized physician order entries, CPOEs, have advantages including but not limited to the

following: avoiding errors such as trailing zeros, the speed of reaching the pharmacy, being

linked to drug interaction warnings faster and easier, and removing the difficulty of deciphering

illegible handwriting. However, Koppel states that there are still many other problems that can

occur with CPOEs, such as selecting the wrong patient or wrong dose. So although it helps

decrease medication errors, the healthcare staff need to still use their own knowledge as well. It

is important to prevent these medication errors because the study stated that about 770,000

patients have been killed by serious drug errors.

Another study has also discussed and studied CPOEs, but it also included the use of decision

support. This comparison study followed all patients in three medical surgical units for seven to

ten weeks during four separate times in the course of four years. It studied how CPOEs decrease

medication errors and how CPOEs with decision support to warn about any medication

interactions or allergies to the medications can also decrease medication errors. This has a

substantial effect. Bates found that, during this study, the medication error rate fell significantly,

by 81 percent. This was not including missed dose errors. The amount of errors in this study

went from 142 per 1,000 patient-days in the beginning to 26.6 per 1,000 patient-days in the end

(P < 0.0001). Bates also found that serious non-intercepted medication errors fell 86 percent

from baseline to period 3, the final period (P = 0.0003). This is substantial because these errors
PREVENTING MEDICATION ERRORS IN THE HOSPITAL 6

have the possibility to cause harm to the patient. The significant disparities were found in each

type of medication error, including errors of substitution, dose, frequency, and allergies. CPOEs

alone already decrease the occurrence of medication errors, and with decision support to give

healthcare providers warnings about vital information, the occurrence of these errors decreases

significantly more.

Synthesis

According to Bates, medication errors were cut substantially, by about 81%, when

computerized physician medication order entries were utilized instead of handwritten

prescriptions from physicians. This enormous difference was seen in every type of

medication error, from dose or frequency errors to allergies and interactions. This study goes

on to show that medication errors are decreased more when health care providers receive

decision support to help determine the best medication and accurate dose. Decision support

allows the healthcare team to become aware of any serious drug interactions or allergies that

they may have missed. Interviewed healthcare providers also agree with the use of CPOEs.

Koppel goes on to describe the multitude of benefits from using CPOEs, such as avoiding

trailing zeros mistakes, improved timing to pharmacy, and removing the difficulty of

deciphering illegible handwriting. This can decrease the amount of healthcare costs, as the

first study determined that adverse medication errors can cost hospitals about $2 billion

annually. Medication errors can also harm or kill the patient, so CPOEs improve patient

safety. Although CPOEs are a great tool for preventing medication errors, mistakes can still

be made if the healthcare provider does not identify the correct patient and dose. Some

mistakes include the provider accidentally giving the medication to the wrong patient

because they failed to ensure it is the correct patient, or they might give the wrong dose by
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not reading the prescribed dose and checking that the dose to be given is identical. If the

medications get mixed up and the nurse grabs a medication that was in the wrong spot

without checking, they could give the wrong medication to the patient.

Clinical Recommendations

Because of the tremendous reduction of medication errors, it is highly

recommended that every hospital use CPOEs in practice. CPOEs along with accurate patient

and dose identification can minimize the chance of medication errors. This will improve

patient safety by protecting the patient from adverse drug effects, and it will decrease

hospital costs. If a hospital has multiple medication errors that result in injury or death, it can

ruin the reputation of the hospital. Patients will become hesitant to receive care from the

hospital and will go elsewhere to feel safer. Decision support can also help prevent

medication errors when used alongside with CPOEs. It will provide important information

and warnings that the healthcare team may not have recognized, as it is difficult to remember

all adverse drug interactions. CPOEs benefit both the hospital and the patients.
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Reference

Bates, D. W. (1998). Effect of Computerized Physician Order Entry and a Team Intervention

on Prevention of Serious Medication Errors. Jama, 280(15), 1311.

doi:10.1001/jama.280.15.1311

Fayaz-Bakhsh, A., & Khezri, S. (2014). The impact of computerized physician order entry on

medication error prevention. International Journal of Clinical Pharmacy, 36(6), 1097-

1098. doi:10.1007/s11096-014-0027-6

Koppel, R. (2005). Role of Computerized Physician Order Entry Systems in Facilitating

Medication Errors. Jama, 293(10), 1197. doi:10.1001/jama.293.10.1197