Psychiatry medication errors reduced with e-reports/Rxs

In the largest study of its kind, medication errors were greatly reduced after electronic prescribing systems and computerized error reporting systems were installed in a hospital’s psychiatric unit.

Geetha Jayaram, MD, associate professor, Johns Hopkins University School of Medicine, and colleagues studied the medication error rates in the psychiatry ward of Johns Hopkins Hospital before and after the systems were installed. Their findings were published in a recent issue of the Journal of Psychiatric Medicine.

Over a span of 5 years, researchers looked at the impact of implementation after adoption of the Provider Order Entry (POE) electronic prescribing system and the Patient Safety Net system for reporting errors online. The study involved 65,466 patient days and 617,524 billed prescription doses. Adverse drug events from randomly chosen 2003 charts were compared to patient charts from 2005 and 2007.

Researchers found a reduction in the reported medication error rate from 27.89 errors per 1,000 patient days in 2003 to 5.5 errors in 2005 and 3.43 in 2007. Adverse drug events also fell from 369 in 2003 to 148 in 2005 and 89 in 2007. No major medication errors resulting in death occurred during the study period.

“With the use of electronic ordering, training of personnel, and standardized information technology systems, it is possible to eliminate dangerous medication errors,” Jayaram said.

Success in the use of these systems can also be attributed to deliberate creation of a “culture of safety,” according to Jayaram. “This is done through annual safety training, reporting of all adverse events as they occur, and feedback that focuses not on blaming or shaming, but on how to prevent an error from happening again through education and corrective action,” reported a statement from Johns Hopkins University School of Medicine.