Too much technology may lead to medication errors

In years past, patients’ medical records were stored in color-coded paper filing systems and charts. Prescriptions were handed out on a piece of paper, scrawled with the doctor’s often-untidy signature, to be handed to the clerk at the pharmacy counter who would then dispense the drug. These days, however, doctors, hospitals and pharmacies in Pennsylvania have turned to electronic means to keep track of patient records. Everything, from a medical exam to the administration of medications is recorded electronically, and prescriptions are sent to the pharmacy straight from the physician’s computer. While it may seem that upgrades in technology would lead to upgrades in patient care, this is not always the case.

According to recent data, computer prescriber order entry (CPOE) systems are the biggest factor with regards to medication mistakes in Pennsylvania. Health care facilities in Pennsylvania reported almost 890 incidents of medication mistakes in the first six months of 2016, in which health care information technology was a factor. Most errors were regarding not including dosages or giving the wrong dosages, through an overdose or providing a patient with extra doses.

The Pennsylvania Patient Safety Reporting System (PA-PSRS) included a new question on its form in 2015: did health care information technology cause or play a role in the event. PA-PSRS is a secure system on the Internet in which health care facilities must report when an “incident” or “serious event” occurs. According to the Pennsylvania Patient Safety Authority, errors due to health care information reached the patient nearly 70 percent of the time. However, only about 1 percent of errors actually hurt the patient.

Most errors involved anticoagulants, insulin and opioids. The three cited medication mistake events were “other” at approximately 21 percent, omitting a dose at approximately 14 percent, giving the wrong dose at almost 11 percent and providing extra dosages at approximately 11 percent. CPOE systems were often a factor in such events. For example, approximately 60 percent of dose omissions involved CPOE systems. Approximately 56 percent of extra doses involved CPOE systems. Finally, approximately 53 percent of wrong dosages involved CPOE systems.

As you can see, CPOE systems are often at the heart of medication errors. It is important that physicians and pharmacies check and double-check information on CPOE systems, so that such mistakes can be prevented in the future.

Source:, “Half of Medication Errors Involve CPOE, Data Shows,” Alexandra Wilson Pecci, March 17, 2017