Patient Safety Topics
:
Prescribing Errors
Overview

Errors that occur in the prescribing phase of the medication use process are less likely to reach the patient and cause harm because of the opportunity to intercept the error in the phases of transcribing, dispensing, administering, and monitoring. However, some prescribing errors make their way through the entire medication use process, reach the patient, and cause harm. It is important that stakeholders, including healthcare organizations and health information technology vendors, continue to develop, implement, and refine systems to better support prescribers and make it easier to select the correct action.

Key Data and Statistics

​Pennsylvania Patient Safety Authority analysts queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) database for Serious Events resulting from medication errors, associated with the prescribing phase, that occurred from July 2004 through June 2016. This query yielded 837 event reports. Twenty-six reports (3.1%) were excluded from final analysis because the error likely did not originate with the prescribing phase; a total of 811 event reports remained for final analysis.

The majority (67.7%, n = 549 of 811) of the Serious Events were reported as an error that occurred that may have contributed to or resulted in temporary harm to the patient and required intervention. Nearly 5% (n = 38) either required intervention necessary to sustain life or contributed to or resulted in the patient’s death.

Figure 1. Harm Scores for Serious Events Associated with Prescribing Errors, as Reported to the Pennsylvania Patient Safety Authority, July 2004 through June 2016 (N = 811)

Figure 1. Harm Scores for Serious Events Associated with Prescribing Errors, as ReportedNearly 40% (n = 319) of the events involved opioids, anticoagulants, and insulin—high-alert medications that pose an increased risk of patient harm when involved in medication errors.8 Figure 2 shows the five most common drug classes involved in the reported events.

 

Figure 2. Most Common Drug Classes Involved in Serious Events Associated with Prescribing Errors, as Reported to the Pennsylvania Patient Safety Authority, July 2004 through June 2016 (N = 811)

Figure 2. Most Common Drug Classes Involved in Serious Events Associated with Prescribing Errors, as Reported * High-alert medication

Educational Tools

Computerized Prescriber Order Entry (CPOE) System Evaluation
To ensure CPOE systems with clinical decision support are performing well and as expected, it is important for healthcare organizations to regularly test these systems. The accompanying list of unsafe orders was compiled after an analysis of Serious Events associated with prescribing errors that were reported to the Authority.

Multimedia

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