A qualitative study of prescribing errors among multi-professional prescribers within an e-prescribing system

Fahad Alshahrani,John F. Marriott,Anthony R. Cox

doi:10.1007/s11096-020-01192-0

Abstract

Background Computerised Physician Order Entry (CPOE) is considered to enhance the safety of prescribing. However, it can have unintended consequences and new forms of prescribing error have been reported. Objective The aim of this study was to explore the causes and contributing factors associated with prescribing errors reported by multidisciplinary prescribers working within a CPOE system. Main Outcome Measure Multidisciplinary prescribers experience of prescribing errors in an CPOE system. Method This qualitative study was conducted in a hospital with a well-established CPOE system. Semi-structured qualitative interviews were conducted with prescribers from the professions of pharmacy, nursing, and medicine. Interviews analysed using a mixed inductive and deductive approach to develop a framework for the causes of error. Results Twenty-three prescribers were interviewed. Six main themes influencing prescribing were found: the system, the prescriber, the patient, the team, the task of prescribing and the work environment. Prominent issues related to CPOE included, incorrect drug name picking, default auto-population of dosages, alert fatigue and remote prescribing. These interacted within a complex prescribing environment. No substantial differences in the experience of CPOE were found between the professions. Conclusion Medical and non-medical prescribers have similar experiences of prescribing errors when using CPOE, aligned with existing published literature about medical prescribing. Causes of electronic prescribing errors are multifactorial in nature and prescribers describe how factors interact to create the conditions errors. While interventions should focus on direct CPOE issues, such as training and design, socio-technical, and environmental aspects of practice remain important.

Highlights

Medication errors, defined as ‘a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient’ [1], are responsible for significant morbidity and mortality, as well as increased costs of healthcare [2, 3]
Our study found that the causes and contributing factors to electronic prescribing errors described by prescribers from different professions are multifactorial and interconnected
The causes and contributing factors of electronic prescribing errors reported from different prescribers were similar to many of the prescribing errors that occur with conventional handwritten prescribing [5, 28, 29] with the addition of errors related to the electronic system

Summary

Introduction

Medication errors, defined as ‘a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient’ [1], are responsible for significant morbidity and mortality, as well as increased costs of healthcare [2, 3]. The World Health Organisations Third Global Patient Safety Challenge is focused on a reduction in medication errors by 50% [4] and reducing prescribing errors is a key part of this drive. Computer Physician Order Entry systems (CPOEs) are seen as essential for improving both efficiency and patient safety in relation to prescribing [2, 8,9,10]. CPOE enables prescribers to enter drug prescriptions via a computer application rather than paper. Entry (CPOE) is considered to enhance the safety of prescribing. It can have unintended consequences and new forms of prescribing error have been reported

Methods

Discussion

Conclusion