Study Lays Bare Residents' E-Medication Prescribing Errors

In academic teaching hospitals, medical residents typically enter most of their medication orders for patients by using electronic prescribing systems. However, little is known about the association between the residents’ level of training and the frequency of medication prescribing errors or when they occur. A recent study helps shed light on these errors.

The results of a retrospective cohort study on medication e-prescribing errors made by 335 internal medicine residents in an academic medical center were published in the January 2019 issue of Southern Medical Journal.¹ The study looked at more than 1.7 million inpatient electronic medication orders placed from 2011 to 2015. The objectives of the study were to analyze the frequency and types of resident medication e-prescribing errors, their association with the postgraduate year (PGY) of residency training, and the time of day and month that the errors occurred.

Here are highlights of the study¹:

Frequency and Harm

Pharmacists identified an error in about 4% of the residents’ medication orders. None of the errors resulted in patient harm, because the pharmacists identified and corrected them before the medications reached the patients.

Medications

Medication classes associated with the highest rates of pharmacy-detected errors were antimicrobials (14%), anticoagulants (9%), colony-stimulating factor agents (8%), biologicals (8%), and antidotes (6%). Among these medications:

• Errors with antimicrobials were most often associated with lack of renal dose adjustments/monitoring (69%), incomplete or unclear orders (17%), and allergies (5%)
• Errors with anticoagulants were most often associated with lack of renal dose adjustments/monitoring (65%), duplicate therapy (18%), and incomplete or unclear (14%).
• Aside from antimicrobials and anticoagulants, medications prescribed infrequently by residents had the highest rates of prescribing errors.

Timing

• Errors were most frequent in August and least frequent in July. The researchers thought that the lower error rates in July could be because of heightened supervision during the first month of residency training and higher error rates in August could be the result of residents’ growing confidence and realization that all medication orders are verified by a pharmacist.
• Resident errors were highest during the day. They peaked in the morning, which the researchers thought might be the result of the type and volume of daytime orders and multitasking.
• Resident errors were less frequent than expected during transition periods, such as 7-9 am and 5-7 pm, which the researchers thought could be because of the use of handoff tools (eg, SBAR [Situation, Background, Assessment, Recommendation]) or failure to detect errors that originate during transition periods, because they may not manifest right away.

Training Level

• PGY-1 and PGY-3 residents committed more errors than PGY-2 residents. Researchers suggested this difference may be related to fewer consultations with others before placing orders, an increase in patient and therapy complexities, and knowledge decay.
• The highest frequency of medication e-prescribing errors occurred during PGY 1. The researchers thought that the decrease in errors observed between PGY 1 and PGY 2 could be the result of better medication knowledge and familiarity with the electronic health record (EHR).

Types

• Overall, and for each PGY level, the most common errors were failure to adjust dosing or monitor for renal impairment (40%), incomplete or unclear orders that needed clarification (27%), duplicate therapy (25%), drug interaction (5%), and prescribing a drug to which a patient may be allergic (4%)

STUDY TAKEAWAYS¹

Add resident supervision. Although autonomy fosters resident learning, do not withdraw resident supervision after the first month of training. The timing of errors suggests the need for increased supervision in August and September, not just in July.

Continue pharmacy support. The frequency of resident e-prescribing errors underscores the need and value of ongoing pharmacy review of all residents’ medication orders, particularly given the widespread fatigue that contributes to bypassing EHR error detection functionality.

Educate residents. Inform them about common errors when ordering certain types of medications, particularly anticoagulants, antidotes, antimicrobials, biologicals, and colony-stimulating factor agents, as well as the different types of errors seen with com- monly versus less commonly prescribed medications.

Encourage consultation. Urge PGY-3 residents to consult with other health care professionals when caring for complex patients or ordering medications prescribed infrequently.

Strengthen renal dosing/monitoring capabilities. Establish a reliable plan to ensure medication dose adjustment and monitoring for patients with renal impairment, particularly when certain anti-coagulants and antimicrobials are prescribed. One way to accomplish this is with a pharmacy renal dosing protocol that targets at-risk patients and medications.

REFERENCE

Garber A, Nowacki AS, Chaitoff A, et al. Frequency, timing, and types of medication ordering errors made by residents in the electronic medical records era. South Med J. 2019;112(1):25-31. doi: 10.14423/SMJ.0000000000000923.

Michael J. Gaunt, PharmD, is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/ Ambulatory Care Edition.