HARRISBURG: The Patient Safety Authority today released detailed results from a recent voluntary assessment of electronic pharmacy systems in Pennsylvania facilities in a Supplementary Advisory. Because the results show pharmacy computer systems in the facility assessment are not detecting all unsafe drug orders, the Authority encourages all Pennsylvania facilities to test their systems to ensure they are catching potentially harmful medication errors.
An example in the Advisory suggests that a pharmacy computer system in one case failed to stop two potentially dangerous orders when a 30-year-old patient was ordered two prescriptions of different painkillers which resulted in an overdose of acetaminophen by 1,750 mg within two days. While the patient did not suffer severe liver damage from the overdose, the risk is there for a more serious outcome.
“This is just one example of the problems we found with the pharmacy systems,” said Mike Doering, interim executive director of the Patient Safety Authority. “Many of the systems performed poorly when tested with specific unsafe medication orders to assess their ability to detect serious or fatal errors they reported to us. None of the 30 systems tested in the workgroup were able to detect all unsafe orders presented in the field test, and one system only detected one unsafe order.”
Staff from the Pennsylvania Patient Safety Reporting System (PA-PSRS) conducted the assessment with 30 volunteer participants from Pennsylvania hospitals as part of a Workgroup on Pharmacy Computer System Safety. The methodology of the assessment was based on a similar evaluation performed nationally by the Institute for Safe Medication Practices (ISMP), a subcontractor of the Authority. The objective of the workgroup was to assess the safety features and capabilities of pharmacy computer systems used in Pennsylvania hospitals.
Requirements for workgroup participation included: creating a fictitious patient in the pharmacy computer system; entering a test of 18 unsafe medication orders, provided by PA-PSRS, into the fictitious patient’s profile; recording whether or not the pharmacy computer system detected the unsafe orders; and completing a brief online questionnaire. The survey is a follow-up to similar surveys ISMP has done nationally regarding the reliability of electronic pharmacy computer systems. ISMP received similar results in their national surveys of hospital pharmacy computer systems.
Doering added that since participants were not randomly selected, the field tests cannot be generalized to all Pennsylvania facilities. However, he said, hospital pharmacy computer systems continue to allow users to override serious warnings. Doering encouraged all facilities to test their pharmacy computer systems more frequently to ensure they are using the error-catching features to their full potential and to ensure the systems are capable of preventing these errors.
“Only 40 percent of the systems tested were able to detect a serious overdose of a potentially lethal drug for a four-year-old child and in an adult the same drug overdose was caught only half the time,” said Doering. “Less than a third of the systems detected a potential fatal overdose of a drug for a patient being treated for rheumatoid arthritis.
“New or updated technology is part of the solution to reducing the risk of error, but there is always a danger of relying too much on technology as a safety net,” added Doering. “Pharmacists should not rely on this tool alone to detect potentially harmful medication errors. They should work with staff and communicate problems on a regular basis to prevent future errors.”
The Authority also suggests that facilities maximize their systems’ capabilities whenever possible by responding to serious error-prone situations reported in the Patient Safety Advisory and other safety publications. It also suggests that facilities consider participating in the Leapfrog Group’s Simulator, expected to be released in 2007, to test their computerized prescriber order entry (CPOE) systems for safety performance. The results will serve as a roadmap to promote improved pharmacy computer technology for more effective detection of significant drug errors.
For a copy of the 2007 May Supplementary Advisory go to the Authority’s website at www.patientsafetyauthority.org or click on the following link http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2007/may31_4(suppl2)/Pages/home.aspx.
BACKGROUND
The Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act, to help reduce and eliminate medical errors by identifying problems and recommending solutions that promote patient safety. Under the Act, all Pennsylvania-licensed hospitals, ambulatory surgical facilities, birthing centers and certain abortion facilities are required to report Serious Events and Incidents to the Authority.
More than 485 healthcare facilities are subject to Act 13 reporting requirements. Facilities submit reports of Serious Events and Incidents through the Pennsylvania Patient Safety Reporting System (PA-PSRS), a confidential web-based system that was developed for the Authority under a contract with ECRI Institute, a Pennsylvania-based independent, non-profit health services research agency, in partnership with EDS, a leading international, information technology firm, and the Institute for Safe Medication Practices (ISMP), also a Pennsylvania-based, non-profit health research organization.
More than 520,000 reports have been submitted through PA-PSRS since the program was initiated in June 2004. Approximately 96 percent of these reports are Incidents or “near-misses.” Based on those reports, the Authority issues quarterly Patient Safety Advisories to educate hospitals and other healthcare facilities about steps they can take to reduce and prevent patient harm. Occasionally, if reports are submitted that demand immediate attention, a Supplementary Advisory focusing on that one particular topic will be issued. The public cannot submit reports through PA-PSRS.
For more information on the Patient Safety Authority, PA-PSRS or previous Patient Safety Advisories, visit the Authority’s website at www.patientsafetyauthority.org.
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