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. 2021 Aug;43(4):884-892.
doi: 10.1007/s11096-020-01192-0. Epub 2020 Nov 9.

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

Fahad Alshahrani  1   2 , John F Marriott  1 , Anthony R Cox  3
Affiliations

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

Fahad Alshahrani et al. Int J Clin Pharm. 2021 Aug.

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.

Keywords: CPOE; Clinical pharmacy; Electronic prescribing; Prescribing.

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Conflict of interest statement

The authors have no conflicts of interest to declare.

Figures

Fig. 1
Fig. 1
Conceptual figure of the interaction of the six major themes leading to the production of a prescription
See this image and copyright information in PMC

References

    1. Ferner RE, Aronson JK. Clarification of terminology in medication errors. Drug Saf. 2006;29(11):1011–1022. doi: 10.2165/00002018-200629110-00001. - DOI - PubMed
    1. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington, DC: National Academies Press; 2000. - PubMed
    1. Smith J, Cavell G. Building a safer NHS for patients: improving medication safety. London: Department of Health; 2004.
    1. Donaldson LJ, Kelley ET, Dhingra-Kumar N, Kieny M-P, Sheikh A. Medication without harm: who's third global patient safety challenge. Lancet. 2017;389(10080):1680–1681. doi: 10.1016/S0140-6736(17)31047-4. - DOI - PubMed
    1. Dornan T, Ashcroft D, Heathfield H, Lewis P, Miles J, Taylor D, et al. An in-depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education: EQUIP study. London: General Medical Council. 2009. [cited 2020 Oct 2]. https://www.gmc-uk.org/-/media/documents/FINAL_Report_prevalence_and_cau....

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