OJPed  Vol.3 No.2 , June 2013
Failure to prevent medication errors: We need smarter nearly error proof systems
Abstract: Purpose: To determine if nurses are able to identify medication errors that have the potential to bypass computer physician order entry (CPOE) and smart ordering systems. Background: Medical care systems employ computer “smart” systems to reduce medication errors by using artificial intelligence (preprogrammed methods of decision support and error reduction). However, these systems are not perfect and they can be bypassed. Nurses who carry out the order represent the last check point in error prevention prior to the administration of medication orders. Methods: A paper exercise was created with 513 physician orders. Nurses were asked to indicate whether they would carry out the order, refuse to carry out the order, consult a pharmacist for clarification, or carry out the order with special precautions. Nurses were given the option of using any nursing or medical reference. Results: The rate of correctly identifying 23 of the contraindicated orders was low. Both experienced and inexperienced nurses had high rates of not identifying the errors despite similar use of references and requests for assistance from pharmacists. Conclusions: This study demonstrates that if an error escapes a smart system, nurses were able to identify most of these errors, but not all of these. The current system features high stress, self-esteem issues, time pressure, high volume, and high risk. The system must change radically to meet the public’s expectations of being nearly error free which can only be achieved with smarter systems that are more resistant to human errors.
Cite this paper: Yamamoto, L. , Watanabe, K. and Kanemori, J. (2013) Failure to prevent medication errors: We need smarter nearly error proof systems. Open Journal of Pediatrics, 3, 65-73. doi: 10.4236/ojped.2013.32013.

[1]   Conroy, S., Sweis, D., Planner, C., Yeung, V., Collier, J., Haines, L. and Wong, I.C. (2007) Interventions to reduce dosing errors in children: A systematic review of the literature. Drug Safety, 30, 1111-1125. doi:10.2165/00002018-200730120-00004

[2]   Kaushal, R., Barker, K.N. and Bates, D.W. (2001) How can information technology improve patient safety and reduce medication errors in children’s health care? Archives of Pediatrics & Adolescent Medicine, 155, 1002-1007.

[3]   Pedersen, C.A., Schneider, P.J. and Scheckelhoff, D.J. (2009) ASHP national survey of pharmacy practice in hospital settings: Dispensing and administration—2008. American Journal of Health-System Pharmacy, 66, 926-946. doi:10.2146/ajhp080715

[4]   Yamamoto, L. and Kanemori, J. (2010) Comparing errors in ED computer-assisted vs conventional pediatric drug dosing and administration. American Journal of Emergency Medicine, 28, 588-592. doi:10.1016/j.ajem.2009.02.009

[5]   Rothschild, J.M., Keohane, C.A., Cook, E.F., Orav, E.J., Burdick, E., Thompson, S., Hayes, J. and Bates, D.W. (2005) A controlled trial of smart infusion pumps to improve medication safety in critically ill patients. Critical Care Medicine, 33, 533-540. doi:10.1097/01.CCM.0000155912.73313.CD

[6]   Macdonald, M. (2010) Patient safety: Examining the adequacy of the 5 rights of medication administration. Clinical Nurse Specialist, 24, 196-201. doi:10.1097/NUR.0b013e3181e3605f

[7]   Jones, J.H. and Treiber, L. (2010) When the 5 rights go wrong: Medication errors from the nursing perspective. Journal of Nursing Care Quality, 25, 240-724. doi:10.1097/NCQ.0b013e3181d5b948

[8]   Elliott, M. and Liu, Y. (2010) The nine rights of medication administration: An overview. British Journal of Nursing, 19, 300-305.

[9]   Committee on Pediatric Emergency Medicine (2007) Patient safety in the pediatric emergency care setting. Pediatrics, 120, 1367-1375.

[10]   Senger, C., Kaltschmidt, J., Schmitt, S.P., Pruszydlo, M.G. and Haefeli, W.E. (2010) Misspellings in drug information system queries: Characteristics of drug name spelling errors and strategies for their prevention. International Journal of Medical Informatics, 79, 832-839. doi:10.1016/j.ijme dinf.2010.09.005

[11]   Institute for Safe Medication Practices (2011) ISMP’s list of confused drug names.

[12]   Hicks, R.W., Becker, S.C. and Cousins, D.D. (2008). MEDMARX data report. A report on the relationship of drug names and medication errors in response to the Institute of Medicine’s call for action. Center for the Advancement of Patient Safety, US Pharmacopeia, Rockville.

[13]   Young, J., Slebodnik, M. and Sands, L. (2010) Bar code technology and medication administration error. Journal of Patient Safety, 6, 115-120. doi:10.1097/PTS.0b013e3181de35f7

[14]   Koppel, R., Wetterneck, T., Telles, J.L. and Karsh, B.T. (2008) Worka-rounds to barcode medication administration systems: Their occurrences, causes, and threats to patient safety. Journal of the American Medical Informatics Association, 15, 408-423. doi:10.1197/jamia.M2616