At the turn of the new century, the Institute of Medicine (IOM) released a report titled, “To Err is Human: Building a Safer Health System”. Citing a number of large studies, the IOM report stated that each year approximately 50,000–100,000 people die in America because of preventable adverse events (PAE). These PAEs or medical errors are among the leading causes of death, ranking higher than breast cancer, AIDS and motor vehicle accidents in terms of the number of fatalities caused. One major contributor to PAEs is medication-related errors, which are costly to both patients and the healthcare system, resulting in thousands of deaths and costing a hospital up to $3 million dollars annually.
When it comes to medication errors, part of the problem is the multiple steps involved in the administration of a drug. In the inpatient setting, the healthcare provider writes the medication order on an order sheet in the patient’s chart. A nurse processes the order and sends it to the pharmacy where it is reviewed and the drug is dispensed; the nurse ultimately administers the medication. This process is susceptible to a system break down at several different points. The prescription order may be incomplete or illegible. A drug allergy or drug-drug interaction may go unnoticed. There could be mix-ups in dosing or the route of administration of the drug.
As a response to the problem of medication errors, over the course of the last several years, e-prescription systems have emerged as an alternative method for entering drug orders. With an e-prescription system, the healthcare provider enters the medication order into the computer, the order is received by the pharmacy, and the medication is dispensed. Most e-prescription systems have drop down menus, which give the provider the opportunity to select among several dosing options, routes of administration, etc. Furthermore, these systems allow the provider to enter data about a patient’s past medical history, drug allergies, current medications, and recent lab results. The computerized system has the ability to notify providers if there is a drug allergy, a drug-drug interaction, or another possible adverse event.
Few studies have looked at how e-prescribing systems compare to traditional systems in their potential to reduce medical errors. However, a study from Australia published two weeks ago in PLoS Medicine examined the impact of e-prescription systems on medication errors in the inpatient setting and demonstrated that these systems are indeed effective. The investigators found that implementation of e-prescription systems resulted in an approximately 60 percent reduction in total medication-error rates, and a 44 percent decrease in serious medical errors, defined as those errors that result in at least a decline in bodily function. In addition, the researchers found that procedural errors such as incomplete or illegible orders were almost completely eliminated after implementation of the new system. Interestingly, the e-prescription system did not affect the rates of drug-allergy related errors or drug-drug interaction related errors; these types of errors were low even prior to the intervention.
Although the PLoS study only looked at medication errors in the inpatient setting, these systems are also used to provide prescriptions for outpatients. With the advent of e-prescriptions on the outpatient side, patients no longer have to take paper prescriptions to the pharmacy. Instead, doctors enter the prescription order into the computerized system and send the order to the pharmacy. Proponents argue that e-prescriptions in the outpatient setting increase compliance because even if the patient looses a prescription or forgets to drop it off at the pharmacy, the pharmacy will remind them when their medication is ready.
With the expansion of these systems in inpatient and outpatient arenas, the use of e-prescription systems is on the rise. Last week, a report from Cal eConnect — California’s government entity for health information exchange — found that e-prescription usage among physicians in the state has increased from 3% in 2007 to 25% in 2011. Recognizing the potential to reduce medication errors, improve patient outcomes, and cut costs, the Center for Medicare and Medicaid Services (CMS) has welcomed this increase in e-prescription system usage and devised an incentive program by charging penalty fees for certain groups of physicians with access to this technology who do not employ it.
However, while e-prescription systems have a great amount of potential, the implementation of these systems does not translate into an elimination of medication-related errors. As the recent PLoS study shows, these errors may occur even in the presence of e-prescriptions. Another important consideration is the cost associated with the implementation of e-prescription systems, which may include networking costs, software licensing fees, training fees, and annual subscription fees. According to the Department of Health and Human Services, a study in 2007 that examined the implementation of an e-prescription system for a psychiatric clinic reported over $40,000 in implementation costs as well as an annual cost of $14,000 for 10 full-time psychiatrists. More studies that could build on the PLoS study and examine the efficacy and cost-effectiveness of these systems would help inform providers, hospitals and policy-makers and enhance the way these systems are used.
Westbrook JI, et al. (2012) Effects of Two Commercial Electronic Prescribing Systems on Prescribing Error Rates in Hospital In-Patients: A Before and After Study. PLoS Med 9(1): e1001164.