IHN Database

Computerized medication dispensing systems do not improve safety

SALT LAKE CITY, UTAH. Adverse drug events - injuries resulting from the use of a drug - are a significant problem, leading to an estimated 41 per cent of all hospital admissions. Computerized systems have been widely installed in an attempt to reduce the rate of adverse drug events (ADEs) occurring in hospitals. Researchers from the Veterans Administration Salt Lake City Health Care System have examined the effects on ADEs of each stage of their computerized medication ordering and administration process.

ADEs which necessitated additional or altered treatment were recorded from medical records over 20 weeks of admissions to the Salt Lake City VA hospital, following the adoption of computerized systems including computerized physician order entry (CPOE). The team found that 483 clinically significant ADEs occurred during 937 hospital admissions - a rate of 51 per cent. A quarter of the hospitalizations had at least one adverse drug event. Almost all (93 per cent) were for adverse reactions to the drugs. Most (61 per cent) of these ADEs occurred during drug ordering, a quarter during monitoring, and 13 per cent during administration. Nine per cent of the ADEs led to serious harm. Many necessitated additional monitoring and interventions. Of particular interest is the finding that only one per cent of all ADEs were actually documented on the patient’s medical record.

The authors report that the most common errors were: failing to anticipate common adverse drug reactions, failing to monitor for such reactions, providing incorrect doses, and giving inappropriate drugs. They explain that certain problems were avoided with the computerized systems, such as reading physicians' orders, however many others were not.

They conclude that ADEs may still occur at high rates when hospitals use CPOE and similar computerized medication systems. They believe that decision support for drug selection, dosing, and monitoring would help lower ADE rates, and add that CPOE systems should not be relied upon to improve medication safety. Simple modifications to the computer program may vastly improve the utility and safety of CPOEs. For example, at the time a physician enters an order for a loop diuretic, CPOE should suggest an order for a potassium supplement and orders for monitoring serum creatinine and potassium levels.
Nebeker, J.R. et al. High Rates of Adverse Drug Events in a Highly Computerized Hospital. Archives of Internal Medicine, Vol.165, May 2005, pp. 1111-1116

Editor’s comment: The finding that over 50 per cent of patients admitted to hospital experience an adverse event from drugs dispensed in the hospital is indeed sobering and clearly underscores the need for vigilance on part of the patient and their advocate.

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