Angela Ai1, Adrian Wong1, Mary Amato1,2, Adam Wright1,3. 1. Department of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA. 2. Department of Pharmacy Practice, MCPHS University, Boston, MA, USA. 3. Department of Biomedical Informatics, Harvard School of Medicine, Boston, MA, USA.
Abstract
Importance: Electronic prescribing promises to improve the safety and clarity of prescriptions. However, it also can introduce miscommunication between prescribers and pharmacists. There are situations where information that is meant to be sent to pharmacists is not sent to them, which has the potential for dangerous errors. Objective: To examine how frequently prescribers or administrative personnel put information intended for pharmacists in a field not sent to pharmacists, classify the type of information included, and assess the potential harm associated with these missed messages. Design, Setting, Participants: Medication record data from our legacy electronic health record were requested for ambulatory care patients seen at an academic medical center from January 1, 2000, to May 31, 2015 (20 123 881 records). From this database, 6 060 272 medication orders met our inclusion criteria. We analyzed a random sample of 10 000 medication orders with internal comments. Main Outcomes and Measures: Reviewers classified internal comments for intent. Comments intended for pharmacists were also sorted into descriptive categories and analyzed for the potential for patient harm. Results: We found that 11.7% of the prescriptions in our sample contained comments that were intended to be sent to pharmacists. Many comments contained information about the dose, route, or duration of the prescription (38.0%). Approximately a third of the comments intended for pharmacists contained information that had the potential for significant or severe harm if not communicated. Conclusion: We found undelivered comments that were clearly intended for pharmacists and contained important information for either pharmacists or patients. This poses a legitimate safety concern, as a portion of comments contained information that could have prevented severe or significant harm.
Importance: Electronic prescribing promises to improve the safety and clarity of prescriptions. However, it also can introduce miscommunication between prescribers and pharmacists. There are situations where information that is meant to be sent to pharmacists is not sent to them, which has the potential for dangerous errors. Objective: To examine how frequently prescribers or administrative personnel put information intended for pharmacists in a field not sent to pharmacists, classify the type of information included, and assess the potential harm associated with these missed messages. Design, Setting, Participants: Medication record data from our legacy electronic health record were requested for ambulatory care patients seen at an academic medical center from January 1, 2000, to May 31, 2015 (20 123 881 records). From this database, 6 060 272 medication orders met our inclusion criteria. We analyzed a random sample of 10 000 medication orders with internal comments. Main Outcomes and Measures: Reviewers classified internal comments for intent. Comments intended for pharmacists were also sorted into descriptive categories and analyzed for the potential for patient harm. Results: We found that 11.7% of the prescriptions in our sample contained comments that were intended to be sent to pharmacists. Many comments contained information about the dose, route, or duration of the prescription (38.0%). Approximately a third of the comments intended for pharmacists contained information that had the potential for significant or severe harm if not communicated. Conclusion: We found undelivered comments that were clearly intended for pharmacists and contained important information for either pharmacists or patients. This poses a legitimate safety concern, as a portion of comments contained information that could have prevented severe or significant harm.
Authors: Corey A Lester; Allen J Flynn; Vincent D Marshall; Scott Rochowiak; Brigid Rowell; James P Bagian Journal: J Am Med Inform Assoc Date: 2022-08-16 Impact factor: 7.942
Authors: Adam Wright; Dustin S McEvoy; Skye Aaron; Allison B McCoy; Mary G Amato; Hyun Kim; Angela Ai; James J Cimino; Bimal R Desai; Robert El-Kareh; William Galanter; Christopher A Longhurst; Sameer Malhotra; Ryan P Radecki; Lipika Samal; Richard Schreiber; Eric Shelov; Anwar Mohammad Sirajuddin; Dean F Sittig Journal: J Am Med Inform Assoc Date: 2019-10-01 Impact factor: 4.497
Authors: Evan W Orenstein; Daria F Ferro; Christopher P Bonafide; Christopher P Landrigan; Scott Gillespie; Naveen Muthu Journal: JAMIA Open Date: 2019-08-07
Authors: Robert J Romanelli; Naomi R M Schwartz; William G Dixon; Carla Rodriguez-Watson; Brian C Sauer; Dawn Albright; Zachary A Marcum Journal: Pharmacoepidemiol Drug Saf Date: 2021-07-28 Impact factor: 2.732