Impact of computerized physician order entry on medication prescription errors in the intensive care unit: a controlled cross-sectional trial

Kirsten Colpaert, 1 Barbara Claus,2 Annemie Somers,3 Koenraad Vandewoude,4 Hugo Robays,5 and Johan Decruyenaere6

Question, Is the introduction of a computerized ICU system (Centricity Critical Care Clinisoft, GE Healthcare) reduced the incidence and severity of medication prescription errors (MPEs)?

Introduction

• In 1999, the Institute Of Medicine reported that 44,000 to 98,000 people annually die in US hospitals as a result of medical errors.Medication errors occurring either in or out of the hospital are estimated to account for at least 7,000 deaths each year.It has been shown that the attributable cost ranges from $10 for a medication error without harm, to more than $5,000 for a serious ADE

• In intensive care unit (ICU) settings, the rate of preventable and potential ADEs is even higher, being almost twice as high as in non-ICUs.This can be attributed to the high number of drugs that ICU patients receive, the preference for intravenous administration and the incidence of organ failure, all of which increase the potential for errors.

• Until now, CPOE has never been shown to decrease patient morbidity or mortality but seems to be especially helpful in preventing minor errors.

• An intensive care information system (ICIS) is a computerized system specifically designed for the ICU.A prospective trial was conducted in a paper-based unit (PB-U) versus a computerized unit (C-U) in a 22-bed ICU of a tertiary university hospital

• The objective of this study was to evaluate and compare the incidence and severity of medication prescribing errors (MPEs) between this CPOE unit and paper-based units.An independent panel evaluated the severity of MPEs.They identified three groups of MPE:

 - minor MPEs (no potential to cause harm)
 - intercepted MPEs (potential to cause harm but intercepted on time)
 - serious MPEs (non-intercepted potential adverse drug events (ADE) or
ADEs, being MPEs with potential to cause, or actually causing, patient harm).

Materials and methods

Setting

The study was conducted in a tertiary care University Hospital over a five week period (21 March to 28 April, 2004). The 22-bed surgical ICU was divided into three adjacent units of 8, 6 and 8 beds.

Study design

A prospective, controlled cross-sectional trial was conducted in two paper-based units (PB-Us; total of 14 beds (8 + 6)) versus one computerized unit (C-U; 8 beds), 10 months after implementation of the ICIS in the latter unit. Patients were randomly assigned to either of these units by an independent nurse. All units had a similar case mix of patients. Medical staff, consisting of five senior intensivists and three residents, rotated continuously over these units, usually on a one-week basis

A surgical ICU-independent clinical pharmacist with experience in medication errors analyzed every medication order of randomly selected patients during this five week period and recorded every possible MPE

All medication and fluid prescriptions were checked for errors in:

1. Drug (brand or generic) name (illegible, abbreviations, wrong name).

2. Dosing (overdose, underdose, dose omitted).

3. Dosage interval (incorrect dosage interval, dosage interval omitted).

4. Pharmaceutical form.

5. Preparation instructions (incorrect or omitted solvent or dilution, if not available on standard nursing charts).

6. Adequate drug monitoring (no monitoring, wrong drug monitoring, if necessary according to normal hospital practice).

7. Route of administration (incorrect route, route omitted). 8. Infusion rate of continuous medication (wrong rate, rate omitted).

9. Double prescriptions.

10. Clinically important drug-drug interactions.

11. Contra-indications to the prescribed drug.

12. Known allergy to the prescribed drug.

Errors were identified within 24 hours after prescription

Results

The C-U and the PB-U each contained 80 patient-days, and a total of 2,510 medication prescriptions were evaluated.

• The incidence of MPEs was significantly lower in the C-U compared with the PB-U (44/1286 (3.4%) versus 331/1224 (27.0%); P < 0.001).

• There were significantly less minor MPEs in the C-U than in the PB-U (9 versus 225; P < 0.001).

• Intercepted MPEs were also lower in the C-U (12 versus 46; P < 0.001), as well as the non-intercepted potential ADEs (21 versus 48; P < 0.001).

• There was also a reduction of ADEs (2 in the C-U versus 12 in the PB-U; P < 0.01). No fatal errors occurred.

• The most frequent drug classes involved were cardiovascular medication and antibiotics in both groups.

• Patients with renal failure experienced less dosing errors in the C-U versus the PB-U (12 versus 35 serious MPEs; P < 0.001).

Conclusion

The ICU computerization, including the medication order entry, resulted in a significant decrease in the occurrence and severity of medication errors in the ICU.

   Reviewed by : Eman Zaghlul