Abstract

Objective

We utilized a computerized order entry system–integrated function referred to as “void” to identify erroneous orders (ie, a “void” order). Using voided orders, we aimed to (1) identify the nature and characteristics of medication ordering errors, (2) investigate the risk factors associated with medication ordering errors, and (3) explore potential strategies to mitigate these risk factors.

Materials and Methods

We collected data on voided orders using clinician interviews and surveys within 24 hours of the voided order and using chart reviews. Interviews were informed by the human factors–based SEIPS (Systems Engineering Initiative for Patient Safety) model to characterize the work systems–based risk factors contributing to ordering errors; chart reviews were used to establish whether a voided order was a true medication ordering error and ascertain its impact on patient safety.

Results

During the 16-month study period (August 25, 2017, to December 31, 2018), 1074 medication orders were voided; 842 voided orders were true medication errors (positive predictive value = 78.3 ± 1.2%). A total of 22% (n = 190) of the medication ordering errors reached the patient, with at least a single administration, without causing patient harm. Interviews were conducted on 355 voided orders (33% response). Errors were not uniquely associated with a single risk factor, but the causal contributors of medication ordering errors were multifactorial, arising from a combination of technological-, cognitive-, environmental-, social-, and organizational-level factors.

Conclusions

The void function offers a practical, standardized method to create a rich database of medication ordering errors. We highlight implications for utilizing the void function for future research, practice and learning opportunities.

中文翻译：

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与药物订购错误相关的风险因素

摘要

客观的

我们利用计算机化的订单输入系统——称为“无效”的集成功能来识别错误订单（即“无效”订单）。使用无效订单，我们旨在 (1) 确定药物订购错误的性质和特征，(2) 调查与药物订购错误相关的风险因素，以及 (3) 探索减轻这些风险因素的潜在策略。

材料和方法

我们在订单无效后 24 小时内通过临床医生访谈和调查以及图表审查收集了无效订单的数据。访谈采用基于人为因素的 SEIPS（患者安全系统工程计划）模型，以表征导致订购错误的基于工作系统的风险因素；图表审查用于确定无效订单是否是真正的药物订购错误，并确定其对患者安全的影响。

结果

在 16 个月的研究期间（2017 年 8 月 25 日至 2018 年 12 月 31 日），有 1074 份药单无效；842 个无效订单是真正的用药错误（阳性预测值 = 78.3 ± 1.2%）。总共有 22% (n  =  190) 的药物订购错误到达患者，至少一次给药，不会对患者造成伤害。对 355 份无效订单进行了采访（33% 的回应）。错误并非与单个风险因素唯一相关，但药物订购错误的原因是多因素的，由技术、认知、环境、社会和组织层面因素的组合引起。

结论

void 功能提供了一种实用的标准化方法来创建一个丰富的药物订购错误数据库。我们强调了利用空函数对未来研究、实践和学习机会的影响。