Report: Hospital Software Often Doesn’t Flag Unsafe Drug Prescriptions

Systems miss almost 40% of potentially harmful drug orders

One of the tools designed to be a “fix” for medical errors isn’t working as well as it should, according to a report from the Leapfrog Group, a nonprofit organization known for rating hospitals on patient safety. Leapfrog conducted a survey of approximately 1,800 hospitals to determine how many use computerized physician order-entry systems to make sure that patients are prescribed and receive the correct drugs and that the medications won’t cause harm.

While most of the surveyed hospitals had a computer-based medication system in place, the systems fell short in catching possible problems, Leapfrog found. Almost 40% of potentially harmful drug orders weren’t flagged as dangerous by the systems. These included medication orders for the wrong condition or the wrong dose, based on variables such as the patient’s size, other illnesses, and potential drug interactions. In addition, computer systems missed approximately 13% of errors that could have resulted in patient deaths.

In an effort to improve patient safety and health care quality, the federal government has been encouraging hospitals to adopt electronic health records—particularly those with medication ordering systems—thanks to the 2009 stimulus package and the 2010 Patient Protection and Affordable Care Act. But there has been resistance from many doctors and advocates, who say design issues can make the software difficult to use or even counterproductive, according to Leapfrog.

The new survey—which was not peer-reviewed—asked participating hospitals to use “dummy patients” to test their systems. The participants entered information for these imaginary patients and submitted a set of medication orders to see which ones got flagged. Mistakes could include orders prescribing an adult dosage for a child.

Although the results were “alarming,” patient safety advocate Helen Haskell said, it’s difficult to know how many of the missed errors would have resulted in actual harm. Ordering the wrong medication can be inconvenient or problematic, but it isn’t always dangerous, and for those that are, hospitals may have other safeguards in place to catch mistakes before they hurt someone. “It really does vary significantly by hospital,” Haskell said.

How well hospitals adapt their software can also play a role in how good they are at preventing and catching mistakes when it comes to ordering medications, said Raj Ratwani, a health care safety researcher in Washington, D.C.

“What these findings indicate—and what many other researchers have shown—is that computerized physician order entry is effective at reducing adverse drug events,” he said. “What we also know … is these electronic health record systems are complex.”

Source: Kaiser Health News; April 7, 2016.