ArticlePloS one2014
Indication alerts intercept drug name confusion errors during computerized entry of medication orders.
Article in PloS one, 2014. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 20 papers, 3 of them syntheses that pooled it.
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The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
20 citing papers in PubMed, 3 syntheses or guidelines pooled it, 46 citations in OpenAlex.
- Indication documentation and indication-based prescribing within electronic prescribing systems: a systematic review and narrative synthesis.BMJ quality & safety · 2023Pooled it
- A systematic literature review of LASA error interventions.British journal of clinical pharmacology · 2021Pooled it
- A systematic review of the types and causes of prescribing errors generated from using computerized provider order entry systems in primary and secondary care.Journal of the American Medical Informatics Association : JAMIA · 2017Pooled it
- Stakeholder views on requiring diagnosis or clinical indication on e-prescriptions.Journal of managed care & specialty pharmacy · 2024Article
- Compulsory Indications in Hospital Prescribing Software Tested with Antibacterial Prescriptions.AMIA Joint Summits on Translational Science proceedings. AMIA Joint Summits on Translational Science · 2024Article
- Examining medication ordering errors using AHRQ network of patient safety databases.Journal of the American Medical Informatics Association : JAMIA · 2023Observational
- Indication alerts to improve problem list documentation.Journal of the American Medical Informatics Association : JAMIA · 2022Article
- Indication or diagnosis should be required on prescriptions.Journal of managed care & specialty pharmacy · 2021Article
- Risk factors associated with medication ordering errors.Journal of the American Medical Informatics Association : JAMIA · 2021Article
- Automated detection of wrong-drug prescribing errors.BMJ quality & safety · 2019Observational
- Article
- Patient Safety: A Deep Concern to Caregivers.Innovations in pharmacy · 2019Article
- Using drug knowledgebase information to distinguish between look-alike-sound-alike drugs.Journal of the American Medical Informatics Association : JAMIA · 2018Article
- Preventing dispensing errors by alerting for drug confusions in the pharmacy information system-A survey of users.PloS one · 2018Article
- Learning from errors: analysis of medication order voiding in CPOE systems.Journal of the American Medical Informatics Association : JAMIA · 2017Article
- Cognitive tests predict real-world errors: the relationship between drug name confusion rates in laboratory-based memory and perception tests and corresponding error rates in large pharmacy chains.BMJ quality & safety · 2017Article
- Systematic Review of Medical Informatics-Supported Medication Decision Making.Biomedical informatics insights · 2017Review
- Evaluating the Potential Severity of Look-Alike, Sound-Alike Drug Substitution Errors in Children.Academic pediatrics · 2016Article
- Patient Safety in Medication Nomenclature: Orthographic and Semantic Properties of International Nonproprietary Names.PloS one · 2015Article
- Clomipramine, clomiphene, and generic drug-dispensing errors.Indian journal of psychiatryArticle
Corrections and comments
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Authors and funding
8 authors at 4 institutions in 1 country.
Funding
Abstract
backgroundConfusion between similar drug names is a common cause of potentially harmful medication errors. Interventions to prevent these errors at the point of prescribing have had limited success. The purpose of this study is to measure whether indication alerts at the time of computerized physician order entry (CPOE) can intercept drug name confusion errors. METHODS AND
findingsA retrospective observational study of alerts provided to prescribers in a public, tertiary hospital and ambulatory practice with medication orders placed using CPOE. Consecutive patients seen from April 2006 through February 2012 were eligible if a clinician received an indication alert during ordering. A total of 54,499 unique patients were included. The computerized decision support system prompted prescribers to enter indications when certain medications were ordered without a coded indication in the electronic problem list. Alerts required prescribers either to ignore them by clicking OK, to place a problem in the problem list, or to cancel the order. Main outcome was the proportion of indication alerts resulting in the interception of drug name confusion errors. Error interception was determined using an algorithm to identify instances in which an alert triggered, the initial medication order was not completed, and the same prescriber ordered a similar-sounding medication on the same patient within 5 minutes. Similarity was defined using standard text similarity measures. Two clinicians performed chart review of all cases to determine whether the first, non-completed medication order had a documented or non-documented, plausible indication for use. If either reviewer found a plausible indication, the case was not considered an error. We analyzed 127,458 alerts and identified 176 intercepted drug name confusion errors, an interception rate of 0.14±.01%.
conclusionsIndication alerts intercepted 1.4 drug name confusion errors per 1000 alerts. Institutions with CPOE should consider using indication prompts to intercept drug name confusion errors.
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.