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Errors Associated with the Errors Associated with the Use of EUse of E--PrescribingPrescribing

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

Associate Physician, Associate Physician, Brigham and WomenBrigham and Women’’s Hospital, Boston, MAs Hospital, Boston, MA

Assistant Professor, Harvard Medical SchoolAssistant Professor, Harvard Medical School

Supported by a grant from the Risk Management Foundation

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AgendaAgenda

Errors associated with eErrors associated with e--prescribingprescribingTaxonomy 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 settingSignificant interest at the local, state, and federal level

100% e-prescribing target for PCPs and specialists at Partners HealthcareUse of e-prescribing as P4P metricNational efforts

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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 positiveBest studied more recently in the inpatient Best studied more recently in the inpatient settingsetting

New errors from use of inpatient CPOE has New errors from use of inpatient CPOE has received significant attentionreceived significant attention

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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 setting

Study goalsStudy goalsDevelop taxonomy to classify errorsDevelop taxonomy to classify errorsDescribe contributing factorsDescribe contributing factors

Range of Errors Associated with e-prescribing

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Key Components of a prescriptionKey Components of a prescription

Drug productDrug productDoseDoseFrequencyFrequencyRouteRouteDispensing quantityDispensing quantityRefill quantitiesRefill quantitiesInstructionsInstructionsIdentification and authentication of prescriberIdentification and authentication of prescriber

MethodsDrafting of Taxonomy

2 sets of electronic prescriptions with errors reviewedConvenience 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 Taxonomy2 focus groups with community pharmacists

Contributing factorsRecreation of prescriptions with errors in native systemConsultation with informatics and IT professionals

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Drug Product Errors Drug Product Errors

Incomplete Drug NameIncomplete Drug NameStrength Omitted or Error in StrengthStrength Omitted or Error in StrengthIncorrect Drug Chosen and Script Incorrect Drug Chosen and Script Manually AlteredManually Altered

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Error in Product StrengthError in Product Strength

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Dose ErrorsDose Errors

Dose OmittedDose OmittedIncorrect DoseIncorrect DoseAmbiguity in Sig FieldAmbiguity in Sig FieldDose IncompleteDose IncompleteOverdoseOverdoseUnderdoseUnderdose

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Ambiguous DoseAmbiguous Dose11.25mg once

a day, or 7.5mg once a

day?

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Ambiguity in Sig FieldAmbiguity in Sig Field

Which do you trust? The

computer or the provider’s

Spanish?

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Route ErrorsRoute Errors

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

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Route IncorrectRoute Incorrect

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

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Frequency ErrorsFrequency Errors

Frequency OmittedFrequency OmittedFrequency ChangedFrequency Changed

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Ambiguous frequency with Ambiguous frequency with incorrect handincorrect hand--written alterationwritten alteration

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Special InstructionsSpecial InstructionsDose MismatchDose MismatchDrug Product Strength MismatchDrug Product Strength MismatchDose Form MismatchDose Form MismatchFrequency MismatchFrequency MismatchRoute Dosage Form MismatchRoute Dosage Form MismatchPRN 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 MismatchQuantity MismatchQuantity MismatchDose and Frequency MismatchDose and Frequency MismatchPRN Indication MismatchPRN Indication MismatchPrevious 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

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Dissecting an Dissecting an ErrorError

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

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

Keyboard vs. pen;

Propagation of previous errorsCarry forward of erroneous information during renewals

Preliminary Recommendations

Possible User InterventionsFocused training on use of e-prescribing module

Hands-on, real-life examples‘Real life’ contextFocus on common errorsOngoing effort

Education about the prescriptionMedical 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-liveExplore different form factors for data entryMonitor for use of free-text in structured fieldsFormalize 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

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Concluding RemarksConcluding Remarks

EE--prescribing has significant potential to prescribing has significant potential to improve medication safetyimprove medication safetyLike all other technologies, eLike all other technologies, e--prescribing prescribing opens doors to new errors. opens doors to new errors.

Causation often multiCausation often multi--factorialfactorialFrustratingly commonFrustratingly common--placeplace

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

Are we still in denial?

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AcknowledgementsAcknowledgements

Thomas Moniz, Thomas Moniz, RPhRPhJeff Rothschild, MD MPHJeff Rothschild, MD MPHMatveyMatvey PalchukPalchuk, MD MS , MD MS Matthew Matthew DitmoreDitmoreHans Kim, MDHans Kim, MD