Examining medication ordering errors using AHRQ network of patient safety databases

Abstract

Background: Studies examining the effects of computerized order entry (CPOE) on medication ordering errors demonstrate that CPOE does not consistently prevent these errors as intended. We used the Agency for Healthcare Research and Quality (AHRQ) Network of Patient Safety Databases (NPSD) to investigate the frequency and degree of harm of reported events that occurred at the ordering stage, characterized by error type.

Materials and methods: This was a retrospective observational study of safety events reported by healthcare systems in participating patient safety organizations from 6/2010 through 12/2020. All medication and other substance ordering errors reported to NPSD via common format v1.2 between 6/2010 through 12/2020 were analyzed. We aggregated and categorized the frequency of reported medication ordering errors by error type, degree of harm, and demographic characteristics.

Results: A total of 12 830 errors were reported during the study period. Incorrect dose accounted for 3812 errors (29.7%), followed by incorrect medication 2086 (16.3%), and incorrect duration 765 (6.0%). Of 5282 events that reached the patient and had a known level of severity, 12 resulted in death, 4 resulted in severe harm, 45 resulted in moderate harm, 341 resulted in mild harm, and 4880 resulted in no harm.

Conclusion: Incorrect dose and incorrect drug orders were the most commonly reported and harmful types of medication ordering errors. Future studies should aim to develop and test interventions focused on CPOE to prevent medication ordering errors, prioritizing wrong-dose and wrong-drug errors.

Keywords: computerized provider order entry (CPOE); ordering errors; patient safety.

Figure 1.

Type of incorrect action by total number of incidents and events that caused severe harm or death.

Figure 2.

(A, B) Direction of errors reported as incorrect dose, incorrect strength/concentration, incorrect timing, and incorrect rate.

Figure 3.

Human and environmental factors that contributed to errors as identified by error reporters. Categories and subcategories ranked in descending order, from most commonly to least commonly reported.

Figure 4.

Near-miss errors by mechanism of recovery. For this analysis, all near-miss errors in which the mechanism of recovery was unknown or missing were excluded (74%).