Hospital pharmacy computer systems may be unreliable

AORN Journal, Nov, 2005

A survey conducted by the Institute for Safe Medication Practices (ISMP) shows that many hospital pharmacy computer systems may not be detecting and correcting prescription errors or pharmacy order entry errors reliably, according to an Aug 30, 2005, news release from the ISMP. To field test when safety warnings appeared, survey participants were asked to create a test patient in their medication order entry system used by pharmacists and place a series of orders associated with actual errors or hazards reported to the ISMP.

Of the 182 systems tested, only four were able to detect all of the unsafe orders, and fewer than half were able to detect orders for medications that exceeded a safe maximum dose. Only one in five computer systems was able to intercept the entry of a contraindicated medication based on the patient's diagnosis or condition (ie, pregnancy), and only one in four was able to detect a clinically significant interaction between 'medications and herbal supplements. When unsafe orders were detected, approximately nine in 10 systems allowed the user to override serious warnings, often by simply pressing a function key.

Most systems were able to provide reports of medication warning overrides and permitted staff members to build alerts for serious error-prone situations. Only half of the systems tested, however, allowed the use of tail man Letters to differentiate look-alike medication names (eg, hydrOXYzine, hydrALAzine), and only 9% allowed users to change the font and color to highlight look-alike medication name pairs.

The poor field test results may be a result of failure to update technology or software. More than half (ie, 56%) of the survey participants were using a system that was at Least five years old with no, recent upgrades, and 38% had been using the same system for eight years or more without upgrades. Certain' types of warnings may be omitted if a medication information providers software vendor deems them unimportant, and important alerts may not appear if the software content is not current or adequate.

Computer Weaknesses Compromise Medication Safety (news release, Huntingdon Valley, Pa: Institute for Safe Medication Practices, Aug 30, 2005) http://www.ismp .org/PR/PR20050830.pdf (accessed 22 Sept 2005).