Indication Alerts Intercept Drug Name Confusion Errors during Computerized Entry of Medication Orders

Background: Confusion between similar drug names is a common cause of potentially harmful medication errors. Interventions to prevent these errors at the point of prescribing have had limited success. The purpose of this study is to measure whether indication alerts at the time of computerized physician order entry (CPOE) can intercept drug name confusion errors. Methods and Findings: A retrospective observational study of alerts provided to prescribers in a public, tertiary hospital and ambulatory practice with medication orders placed using CPOE. Consecutive patients seen from April 2006 through February 2012 were eligible if a clinician received an indication alert during ordering. A total of 54,499 unique patients were included. The computerized decision support system prompted prescribers to enter indications when certain medications were ordered without a coded indication in the electronic problem list. Alerts required prescribers either to ignore them by clicking OK, to place a problem in the problem list, or to cancel the order. Main outcome was the proportion of indication alerts resulting in the interception of drug name confusion errors. Error interception was determined using an algorithm to identify instances in which an alert triggered, the initial medication order was not completed, and the same prescriber ordered a similar-sounding medication on the same patient within 5 minutes. Similarity was defined using standard text similarity measures. Two clinicians performed chart review of all cases to determine whether the first, non-completed medication order had a documented or non-documented, plausible indication for use. If either reviewer found a plausible indication, the case was not considered an error. We analyzed 127,458 alerts and identified 176 intercepted drug name confusion errors, an interception rate of 0.14±.01%. Conclusions: Indication alerts intercepted 1.4 drug name confusion errors per 1000 alerts. Institutions with CPOE should consider using indication prompts to intercept drug name confusion errors

Example Indication Alert for Levothyroxine.

<p>Example Indication Alert for Levothyroxine.</p

Association between Clinician Type, Location, Shift and Probability of an Intercepted Drug Name Confusion Error.

a<p>Resident physician, inpatient location and day shift were used as reference categories. Testing global null hypothesis for model with fluticasone, −2 log likelihood  = 2563.8, chi-square  = 94.9, p<.0001. For model without fluticasone, −2 log likelihood  = 1245.9, chi-square  = 24.6, p<.0001.</p>b<p>p<0.001.</p>c<p>p<0.05.</p

Distribution of Drug Pairs in Intercepted Errors.

a<p>The interception rate is the number of errors (confirmed by clinician chart review) divided by the total number of alerts for that drug.</p>b<p>In this pair, at the time of the alert, the branded names were most common, >90%.</p