Categorization of Medication Safety Errors in Ambulatory Electronic Health Records

Preventable medication errors continue to affect the quality and consistency in the delivery of care. While numerous studies on medication safety have been performed in the inpatient setting, a review of ambulatory patient safety by the American Medical Association found that medication safety errors were the most frequent safety problems in the outpatient arena. The leading cause of ambulatory safety problems, adverse drug events (ADEs), are common, with estimates of more than 2 million ADEs each year in the ambulatory Medicare population alone, and these events are frequently preventable. We conducted an environmental scan that allowed us to create our own categorization schema of medication safety errors in electronic healthcare records (EHRs) found in the outpatient setting and observed which of these were additionally supported in the literature. This study combines data from the California Hospital Patient Safety Organization (CHPSO), with several key articles in the area of medication errors in the EHR era. Method: To best utilize the various EHR ambulatory medication events submitted into CHPSO’s database, we chose to create a framework to bucket the near misses or adverse events (AEs) submitted to the database. This newly created categorization scheme was based on our own drafted categorization labels of events, after a high-level review, and from two leading articles on physician order entry. Additionally, we conducted a literature review of computerized provider order entry (CPOE) medication errors in the ambulatory setting. Within the newly created categorization scheme, we organized the articles based on issues addressed so we could see areas that were supported by the literature and what still needed to be researched. Results: We initially screened the CHPSO database for ambulatory safety events and found 25,417 events. Based on those events, an initial review was completed, and 19,242 events were found in the “Medication or Other Substance” and “Other” categories, in which the EHR appeared to have been a potential contributing factor. This review identified a subset of 2,236 events that were then reviewed. One hundred events were randomly selected for further review to identify common categories. The most common categories in which errors occurred were orders in order sets and plans (n=12) and orders crossing or not crossing encounters (n=12), incorrect order placed on correct patient (n=10), orders missing (n=8), standing orders (n=8), manual data entry errors (n=6), and future orders (n=6). Conclusion: There were several common themes seen in this analysis of ambulatory medication safety errors related to the EHR. Common among them were incorrect orders consisting of examples such as dose errors or ordering the wrong medication. The manual data entry errors consisted of height or weight being entered incorrectly or entering the wrong diagnostic codes. Lastly, different sources of medication safety information demonstrate a diversity of errors in ambulatory medication safety. This confirms the importance of considering more than one source when attempting to comprehensively describe ambulatory medication safety errors.