Unsafe drug orders slipping through in Pennsylvania

Pharmacy computer systems have glitches

A voluntary assessment of electronic pharmacy systems in Pennsylvania facilities showed the systems are not detecting all unsafe drug orders, Pennsylvania's Patient Safety Authority reports . The authority said all Pennsylvania facilities should test their systems to ensure they are catching potentially harmful medication errors.

The authority is an independent state agency created by a 2002 bill to help reduce and eliminate medical errors by identifying problems and recommending solutions that promote patient safety. Under the Medical Care Availability and Reduction of Error Act, all Pennsylvania licensed hospitals, ambulatory surgical facilities, birthing centers, and certain abortion facilities are required to report serious events and incidents to the authority.

A Supplemental Advisory issued by the agency with the assessment results gave an example of a pharmacy computer system that apparently failed to stop two potentially dangerous orders when a 30-year-old patient was ordered two prescriptions of different painkillers that resulted in an overdose of acetaminophen by 1,750 mg within two days. While the patient did not suffer severe liver damage from the overdose, the authority said, there was a risk for a more serious outcome.

"This is just one example of the problems we found with the pharmacy systems," says Mike Doering, interim executive director of the patient safety authority. "Many of the systems performed poorly when tested with specific unsafe medication orders to assess their ability to detect serious or fatal errors they reported to us. None of the 30 systems tested in the workgroup were able to detect all unsafe orders presented in the field test, and one system detected only one unsafe order."

30 hospitals evaluated

Staff from the Pennsylvania Patient Safety Reporting System conducted the assessment with 30 volunteer participants from Pennsylvania hospitals as part of a workgroup on Pharmacy Computer System Safety. Requirements for participation included creating a fictitious patient in the pharmacy computer system, entering a test of 18 unsafe medication orders into the fictitious patient's profile, recording whether the pharmacy computer system detected the unsafe orders, and completing a brief online questionnaire. Doering says that since participants were not randomly selected, the field tests cannot be generalized to all Pennsylvania facilities. But he said hospital computer systems continue to allow users to override serious warnings. He encouraged all facilities to test their pharmacy computer systems more frequently to ensure they are using the error-catching features to their full potential and to ensure the systems are capable of preventing these errors.

"Only 40% of the systems tested were able to detect a serious overdose of a potentially lethal drug for a four-year-old child and in an adult the same drug overdose was caught only half the time," he says. "Less than one-third of the systems detected a potential fatal overdose of a drug for a patient being treated for rheumatoid arthritis. New or updated technology is part of the solution to reducing the risk of error, but there is always a danger of relying too much on technology as a safety net. Pharmacists should not rely on this tool alone to detect potentially harmful medication errors. They should work with staff and communicate problems on a regular basis to prevent future errors."

The authority also suggested that facilities maximize their systems' capabilities whenever possible by responding to serious error-prone situations reported in the Patient Safety Advisory and other safety publications. It also suggested that facilities consider participating in the Leapfrog Group's Simulator, expected to be released this year, to test their computerized prescriber order entry systems for safety performance. The results will be a roadmap to promote improved pharmacy computer technology for more effective detection of significant drug errors, the authority said.

(Editor's note: More information and a copy of the Supplemental Advisory are available online at http://www.psa.state.pa.us.)