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Implementation of Electronic Tracking Systems Leads to Fewer Medication Errors

March 25, 2011

Medication errors are a common occurrence across all fields of medicine. They can be caused by illegible handwriting on prescriptions, medical personnel fatigue, pharmacy dispensing errors that provide the patient with the wrong medication or the wrong dose, and administration mistakes. These medication errors can cause severe adverse events that can lead to hospitalization or death. Of note, although the majority of psychotropics are rarely deadly on their own, their interactions with non-psychotropics, ie, insulin or blood thinners, can be lethal.

Geetha Jayaram, MD, MBA, and colleagues reviewed 65,466 patient days and 617,524 billed doses over a 5-year period at the 88-bed psychiatric unit of Johns Hopkins Hospital in Baltimore. In the first year of the study (2003), they found 27.89 medication errors per 1,000 patients. They implemented the Patient Safety Net (PSN), a web-based medication error reporting system, and the Provider Order Entry (POE) program, a prescribing system that allows prescriptions to be entered directly by medical personnel with the licensure and privileges to do so. Mistakes are reported in the PSN, allowing the physicians to follow up with corrective action when an error occurs. The PSN also categorizes unsafe conditions and near-miss events.

Jayaram and colleagues educated and trained the Johns Hopkins staff on how to use the PSN and the POE in relation to one another. By implementing these programs, the researchers as well as the staff were able to have support for medication dosage selection, medication allergy alerts, drug interactions, and patient identifiers and monitoring. They also conducted chart reviews in an effort to provide a truer estimate in error reduction and provided feedback as the errors occurred.

By using the PSN and POE, the medication error rate decreased to 5.50 per 1,000 patients in 2005 and to 3.43 per 1,000 in 2007. Jayaram and colleagues believe that the use of computerized proctors will allow for less medications errors and there will be a reduction in pharmacist clarification. (J Psychiatr Pract. 2011;17(2):81-88.) —Christopher Naccari


From → Psychiatry

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