11

Errors Associated with the Errors Associated with the Use of E-PrescribingUse of E-Prescribing

Eric Poon MD, MPHEric Poon MD, MPHIS Director of Clinical Informatics, IS Director of Clinical Informatics,

Associate Physician, Associate Physician, Brigham and Women’s Hospital, Boston, MABrigham and Women’s Hospital, Boston, MA

Assistant Professor, Harvard Medical SchoolAssistant Professor, Harvard Medical School

Supported by a grant from the Risk Management Foundation

22

AgendaAgenda

Errors associated with e-prescribingErrors associated with e-prescribingTaxonomy with examplesTaxonomy with examplesContributing factorsContributing factors

E-Prescribing Comes of Age!

Strong evidence that electronic prescribing in the inpatient setting prevents serious medication errors Emerging evidence in the ambulatory setting

Significant interest at the local, state, and federal level 100% e-prescribing target for PCPs and specialists at

Partners Healthcare Use of e-prescribing as P4P metric National efforts

44

Unintended Consequences: The Underbelly Unintended Consequences: The Underbelly of Healthcare Information Technology (HIT)of Healthcare Information Technology (HIT)

Events or outcomes that are neither Events or outcomes that are neither anticipated noranticipated nor the specific goals of the the specific goals of the associated HIT associated HIT May be negative or positiveMay be negative or positive

Best studied more recently in the inpatient Best studied more recently in the inpatient settingsettingNew errors from use of inpatient CPOE has New errors from use of inpatient CPOE has

received significant attentionreceived significant attention

66

New Errors: New Errors: Revisiting an Old PhenomenonRevisiting an Old Phenomenon

New errors observed in the inpatient New errors observed in the inpatient setting (Koppel, Han, Ash)setting (Koppel, Han, Ash)Extend and severity not fully understood in Extend and severity not fully understood in

the outpatient settingthe outpatient settingStudy goalsStudy goals

Develop taxonomy to classify errorsDevelop taxonomy to classify errorsDescribe contributing factorsDescribe contributing factors

Range of Errors Associated with e-prescribing

88

Key Components of a prescriptionKey Components of a prescription

Drug productDrug product DoseDose FrequencyFrequency RouteRoute Dispensing quantityDispensing quantity Refill quantitiesRefill quantities InstructionsInstructions Identification and authentication of prescriberIdentification and authentication of prescriber

Methods Drafting of Taxonomy

2 sets of electronic prescriptions with errors reviewed Convenience sample at CRICO site 1, collected by outpatient

pharmacist and medical director of adult primary care practice (200+ prescriptions)

Electronic prescription reviewed at CRICO site 2 as part of AHRQ-funded project to evaluate new e-prescribing standards

Validation of Taxonomy 2 focus groups with community pharmacists

Contributing factors Recreation of prescriptions with errors in native system Consultation with informatics and IT professionals

1010

Drug Product Errors Drug Product Errors

Incomplete Drug NameIncomplete Drug NameStrength Omitted or Error in StrengthStrength Omitted or Error in Strength Incorrect Drug Chosen and Script Incorrect Drug Chosen and Script

Manually AlteredManually Altered

1111

Error in Product StrengthError in Product Strength

1212

Dose ErrorsDose Errors

Dose OmittedDose Omitted Incorrect DoseIncorrect DoseAmbiguity in Sig FieldAmbiguity in Sig FieldDose IncompleteDose IncompleteOverdoseOverdoseUnderdoseUnderdose

1313

Ambiguous DoseAmbiguous Dose11.25mg once

a day, or 7.5mg once a

day?

1414

Ambiguity in Sig FieldAmbiguity in Sig Field

Which do you trust? The

computer or the provider’s

Spanish?

1515

Route ErrorsRoute Errors

Incorrect RouteIncorrect RouteOmitted and Should Be POOmitted and Should Be POOmitted and should be Other RouteOmitted and should be Other Route

1616

Route IncorrectRoute Incorrect

Underlying cause: Inadequate synonym support in medication lookup ‘Nuva ring’ (not recognized) vs ‘Nuvaring’ (recognized)

1717

Frequency ErrorsFrequency Errors

Frequency OmittedFrequency OmittedFrequency ChangedFrequency Changed

1818

Ambiguous frequency with incorrect Ambiguous frequency with incorrect hand-written alterationhand-written alteration

1919

Special InstructionsSpecial Instructions Dose MismatchDose Mismatch Drug Product Strength MismatchDrug Product Strength Mismatch Dose Form MismatchDose Form Mismatch Frequency MismatchFrequency Mismatch Route Dosage Form MismatchRoute Dosage Form Mismatch PRN is Indicated in Special Instructions but not in the PRN is Indicated in Special Instructions but not in the

Sig. Sig. Duration of Therapy MismatchDuration of Therapy Mismatch Quantity MismatchQuantity Mismatch Dose and Frequency MismatchDose and Frequency Mismatch PRN Indication MismatchPRN Indication Mismatch Previous Special Instructions Carrying over on RenewalPrevious Special Instructions Carrying over on Renewal

2020

Directions that contradict rest of the Directions that contradict rest of the prescriptionprescription

Provider lack of familiarity with ‘alternate dosing’ prescribing method

Factors Contributing to Errors:A Preliminary Look

Categories of Contributing Factors

Technology Factors

Environmental FactorsUser Factors•Knowledge deficit about application features•Knowledge deficit about the prescription •Multi-tasking•Improper use of short-cuts•Improper use of free-text

•User-interface design•Medication dictionary•Data entry form factor

•Lack of time during visit•Placement of computer equipment

2727

Dissecting an ErrorDissecting an Error

What the prescribing module would have looked like…

7.5 mg

Free Text Entry Possible at the

time

Dose field relatively new to clinicians

History

1. Patient’s BP not well controlled on 5mg of Norvasc

qd. Increase to 7.5mg qd

3. Instead of specifying the higher dose in the dose field, provider

entered the dose as free text in the strength/form field

2. Norvasc only available in 2.5mg, 5 mg,and 10mg tablets

3030

Writing prescriptions – do we know how to?Writing prescriptions – do we know how to?

How much training have you received?Has anyone ever shown you this

relationship?

Dose

Strength Take

Dose Dose ≈ Strength x Take≈ Strength x Take

Lisinopril 40mg Lisinopril 40mg po once a daypo once a day

Lisinopril 20mg Lisinopril 20mg tabletstablets

Take one tablet Take one tablet a daya day

Other common contributing factors

Medication dictionary issuesWrong/not available product in dictionary

Multi-tasking/distractions/short-cutsNot seeing/checking what is actually been

typed inKeyboard vs. pen;

Propagation of previous errorsCarry forward of erroneous information

during renewals

Preliminary Recommendations

Possible User Interventions Focused training on use of e-prescribing module

Hands-on, real-life examples ‘Real life’ context Focus on common errors Ongoing effort

Education about the prescription Medical students & physicians in training

Develop mechanism so that prescription errors become teaching tools.

Develop and disseminate best practices for how to incorporate EMR into the visit

Possible Technology Interventions

Usability study/pilot before new features go-live

Explore different form factors for data entry

Monitor for use of free-text in structured fields

Formalize mechanism for using prescription errors as opportunities to improve user-interface design

Examples of recent improvements

Relationship between dose, strength and take

made more explicitWarning appears when

free text instructions are typed in

3737

Concluding RemarksConcluding Remarks

E-prescribing has significant potential to E-prescribing has significant potential to improve medication safetyimprove medication safety

Like all other technologies, e-prescribing Like all other technologies, e-prescribing opens doors to new errors. opens doors to new errors. Causation often multi-factorialCausation often multi-factorialFrustratingly common-placeFrustratingly common-place

Investment in time, energy and Investment in time, energy and mechanism for interventionsmechanism for interventions

Are we still in denial?

3939

AcknowledgementsAcknowledgements

Thomas Moniz, RPhThomas Moniz, RPhJeff Rothschild, MD MPHJeff Rothschild, MD MPHMatvey Palchuk, MD MS Matvey Palchuk, MD MS Matthew DitmoreMatthew DitmoreHans Kim, MDHans Kim, MD