E-prescribing errors

In this month's issue of Prescriber's Letter is a brief article summarizing what I'll call "medication errors version 2.0" (since everything's 2.0 these days .. and 2.0 is ALWAYS better than 1.0) ..

  • Selection error. It'll be easy to click the wrong drug, dose, or dosage form from a list where they all look similar. Topamax is just a slip of the pointer away from Toprol.  It'll also be easy to click on the wrong patient.
  • Assumed dose. Often the doses listed do NOT reflect minimum or maximum doses…just the dose the pharmacy stocks…or the formulary allows. For example, metoprolol is available in 25, 50, and 100 mg strengths…many pharmacies stock only the 50 mg tabs.
  • Alert overload. E-prescribing systems alert you to allergies, interactions, and therapeutic duplication. But not all are significant. When the computer cries wolf too many times, alerts get ignored.
  • Failure to discontinue. Attempting to change a dose sometimes results in a patient getting BOTH the new dose and old dose.

I agree that all of the above is not only possible – but likely.  I've seen every one of the above errors occur with our EMR.  I'll beat the "usability" drum again and suggest that bad design ==> bad medicine. 

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