Prescription errors related to the use of computerized provider order-entry system for pediatric patients

Alhanout, Kamel; Bun, Sok-Siya; Retornaz, K.; Chiche, Laurent; Colombini, Nathalie

doi:10.1016/j.ijmedinf.2017.04.005

Cited by 12 publications

(9 citation statements)

References 21 publications

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“…The control of medical prescriptions is important. Computational systems, which are already in use in several countries, are helpful, but can still have limitations (Alhanout et al 2017). The control of prescriptions is especially important in the case of older persons, who often take the same active substance supplied by a different specialist.…”

Section: Prescription and Sales Of Pharmaceuticalsmentioning

confidence: 99%

How to decrease pharmaceuticals in the environment? A review

Caban

Stepnowski

2021

Environ Chem Lett

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The global problem of the presence of human and veterinary pharmaceuticals in the environment is under investigation. Despite the increase in the knowledge of its sources, fates and impacts, the assessment of risks and the derived prevention actions are limited to single cases. The predicted increasing trend in the usage of pharmaceuticals forces the various parties involved to think about comprehensive mitigation actions. There are many areas of daily human life and industrial operations where such actions should take place. Thereby, in the presented review, such actions were summarized and divided into the following groups: A. design, synthesis and production of pharmaceuticals, B. prescription, sales and waste handling, C. control of the sources with advanced technologies. As the total amount of proposed actions was found to be quite high, a ranking according to the term of effects was proposed using the pyramid of needs. The advantages of actions taken in the first steps of the pharmaceutical life cycle (acting on the upstream) over end-of-pipe actions and the application of advanced technologies (the downstream option) were discussed, with reference to expert opinions.

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Section: Prescription and Sales Of Pharmaceuticalsmentioning

confidence: 99%

How to decrease pharmaceuticals in the environment? A review

Caban

Stepnowski

2021

Environ Chem Lett

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“…Although the use of CPOE is linked to notable improvements in reducing and/ or limiting MEs, others argue that the use of CPOE might facilitate MEs, or CPOE itself could become a source of errors. [14][15][16][17] As an example, a recent study 18 found that nearly 6 percent (63,040) of the MEs reported to MEDMARX-an anonymous, confidential, Internet-accessible, ME-reporting program that is designed and developed by the US Pharmacopeia for hospitals and health systems to systematically collect, analyze, track, and report MEs 19 -between 2003 and 2010 were related to CPOE. Moreover, Amato et al 20 conducted a study to evaluate different CPOE systems at six sites to review potential CPOE-related MEs occurring in the medication ordering phase.…”

Section: Introductionmentioning

confidence: 99%

Computerized provider order entry–related medication errors among hospitalized patients: An integrative review

Elshayib

Pawola

2020

Health Informatics J

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The Institute of Medicine estimates that 7,000 lives are lost yearly as a result of medication errors. Computerized physician and/or provider order entry was one of the proposed solutions to overcome this tragic issue. Despite some promising data about its effectiveness, it has been found that computerized provider order entry may facilitate medication errors. The purpose of this review is to summarize current evidence of computerized provider order entry -related medication errors and address the sociotechnical factors impacting the safe use of computerized provider order entry. By using PubMed and Google Scholar databases, a systematic search was conducted for articles published in English between 2007 and 2019 regarding the unintended consequences of computerized provider order entry and its related medication errors. A total of 288 articles were screened and categorized based on their use within the review. One hundred six articles met our pre-defined inclusion criteria and were read in full, in addition to another 27 articles obtained from references. All included articles were classified into the following categories: rates and statistics on computerized provider order entry -related medication errors, types of computerized provider order entry -related unintended consequences, factors contributing to computerized provider order entry failure, and recommendations based on addressing sociotechnical factors. Identifying major types of computerized provider order entry -related unintended consequences and addressing their causes can help in developing appropriate strategies for safe and effective computerized provider order entry. The interplay between social and technical factors can largely affect its safe implementation and use. This review discusses several factors associated with the unintended consequences of this technology in healthcare settings and presents recommendations for enhancing its effectiveness and safety within the context of sociotechnical factors.

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“…Although the recent medical literature emphasizes the fact that the use of computerized prescription systems can decrease the frequency of prescription errors and iatrogenic adverse events and increase the safety of drug prescriptions, we consider that the system correction algorithm can sometimes generate errors ‐ especially in the setting of rare diseases. Indeed, recent literature on medication errors linked to a computerized physician order entry system emphasized the need to understand and then present the causes of these errors . Since PA is a rare inborn error of metabolism with a small number of patients, some treatments are not referenced and not well known—resulting in medication errors.…”

Section: Discussionmentioning

confidence: 99%

Administration of gamma‐hydroxybutyrate instead of beta‐hydroxybutyrate to a liver transplant recipient suffering from propionic acidemia and cardiomyopathy: A case report on a medication prescribing error

et al. 2020

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Beta‐hydroxybutyrate (BHB) is a synthetic ketone body used as an adjuvant energy substrate in the treatment of patients with metabolic cardiomyopathy. A medication prescribing error led to the administration of the general anesthetic sodium gamma‐hydroxybutyrate (GHB) instead of sodium BHB in a liver transplant recipient with propionic acidemia and cardiomyopathy, causing acute coma. A 15‐year‐old boy suffering from neonatal propionic acidemia underwent liver transplantation (LT) for metabolic decompensation and cardiomyopathy (treated with cardiotropic drugs and BHB) diagnosed a year previously. The patient had been rapidly extubated after LT, and was recovering well. Eight days after LT, the patient suddenly became comatose. No metabolic, immunological, hypertensive, or infectious complications were apparent. The brain magnetic resonance imaging and electroencephalography results were normal. The coma was soon attributed to a medication prescribing error: administration of GHB instead of BHB on day 8 post‐LT. The patient recovered fully within a few hours of GHB withdrawal. The computerized prescription system had automatically suggested the referenced anesthetic GHB (administered intravenously) instead of the non‐referenced ketone body BHB, triggering coma in our patient. A computerized prescription system generated a medication prescribing error for a rare disease, in which the general anesthetic GHB was mistaken for the nonreferenced energy substrate BHB.

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Prescription errors related to the use of computerized provider order-entry system for pediatric patients

Cited by 12 publications

References 21 publications

How to decrease pharmaceuticals in the environment? A review

How to decrease pharmaceuticals in the environment? A review

Computerized provider order entry–related medication errors among hospitalized patients: An integrative review

Administration of gamma‐hydroxybutyrate instead of beta‐hydroxybutyrate to a liver transplant recipient suffering from propionic acidemia and cardiomyopathy: A case report on a medication prescribing error

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