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Lack of communication among health staff: potential sources of medication errors related to CPOEs


Joana González-Arnaiz

Hospital Pharmacist

Lorea Arteche

F Becerril

Pharmacy Service
Virgen del Camino Hospital

E: [email protected]

Communication was the most frequently cited cause (> 60%) of medication errors reported to the Joint Commission on Accreditation of Healthcare Organizations between 1995 and 2003.[1] Such problems included not only communication breakdown between doctors and patients, but also communication among health professionals.

Computerised physician order entry systems (CPOEs) are useful tools that help us avoid many medication errors,[2–6] but clear understanding and communication between members of staff involved in the medication process is essential.[7]

The Virgen del Camino Hospital in Pamplona, Spain, is a 530-bed tertiary-level unit. It has a ­maternity ward with 208 beds and a general area with 322 beds. CPOE with electronic prescription was implemented four years ago and after this time the pharmacy department detected that a continuous lack of communication among healthcare staff (mainly from doctor to nurses) caused numerous real and potential medication errors for patients admitted.

The objective of this study was to analyse the medication errors that occur due to a deficit in the process of communication between healthcare professionals after implementation of a CPOE system integrated into the computerised clinical history of a Spanish hospital.

Four years after the implementation of a CPOE system – in which the doctor requests the prescription, the pharmacist verifies the medication, the pharmacy technicians dispense it, and the responsible nurse prints the labels with the prescription for its later administration to the patient – the pharmacy has detected numerous real and potential medication errors when the physician changes the prescription outside of the schedule established for it, without later warning of such a change to the nurse.

A prospective pharmacist intervention study over 17 random days in March and April 2006 analysed data relating to modifications in prescriptions considered relevant for patients’ therapy (including toxic allergies, overdoses, underdoses, adjustments of dose by renal failure, etc). There were an average of 2,160 prescriptions per day (corresponding to the area of the general hospital, with an average occupation of 260 beds), with 36,720 prescriptions in total. Of the total number of prescriptions analysed, 374 had relevant changes (1% in all) and the nurse was not advised.

The error rate was 23 per 100. The error rate is the number of orders that did or could give rise to an administration error because the physician did not warn the nurse about the modification, divided by the total number of modified orders.

As a safety measure, all changes detected by the pharmacist when validating the medication were collated personally with the nurses, avoiding administration of suspended drugs, drugs to which patients were allergic, overdoses, etc, as well as providing information about the prescription of new drug administrations.

Nurses were advised that before administering the drugs they should review the treatment in the computerised clinical history.

The preventive barriers failed at the moment when doctors made changes in the prescription outside the protocolised schedule, without warning nurses.

The pharmacy department continues to warn nurses of modifications detected, and it is investigating using a computer tool that serves as an alert for the aforementioned changes in prescriptions.

Although the CPOE system contributes to reducing many medication errors that occurred using the handwritten prescription process – order-entry transcription-based errors[8] – it could lead to new types of errors, mainly in the form of administration errors, when nurses do not have the necessary information so that the patient does not receive the suitable medication.

For this reason, besides creating computer tools to act as prevention barriers that alert us and allow to us to decrease errors, we cannot leave to one side the communication between all health professionals who comprise the patient’s welfare team.

Joint Commission

1. Joint Commission on Accreditation of Healthcare Organizations. The Joint Commission. Oakbrook Terrace IL: JCAHO; 2007. Available online at:

2. Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA 1998;280(15):1311-16.

3. Bates DW, Teich JM, Lee J, Seger D, Kuperman GJ, Ma’Luf N, Boyle D, Leape L. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc 1999;6(4):313-32.

4. Kuperman GJ, Gibson RF. Computer physician order entry: benefits, costs, and issues. Ann Intern Med 2003;139:31-9.

5. Potts A, Barr F, Gregory D, Wright L, Patel N. Computerized physician order entry and medication errors in a pediatric critical care unit. Pediatrics 2004;113;1:59-63.

6. Kaushal R, Bates DW. Information technology and medication safety: what is the benefit? Qual Saf Health Care 2002;11:261-5.

7. EGSMP. Creation of a better medication safety culture in Europe: building up safe medication practices. Recommendation of the Council of Europe Expert Group on Safe Medication Practices. Paper presented at International Conference on Patient Safety, Madrid, 16 November 2006.

8. Shulman R, Singer M, Goldstone J, Bellingan G. Medication errors: a prospective cohort study of hand-written and computerised physician order entry in the intensive care unit. Crit Care 2005;9:516-21.

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