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Hospital Software Often Doesn’t Flag Unsafe Drug Prescriptions, Report Finds

Leon County Judge John Cooper on June 30, 2022, in a screen grab from The Florida Channel.
Associated Press
The Florida Channel
Leon County Judge John Cooper on June 30, 2022, in a screen grab from The Florida Channel.

Medical errors are estimated to be the third-highest cause of death in the country. Experts and patient safety advocates are trying to change that. But at least one of the tools that’s been considered a fix isn’t yet working as well as it should, suggests a report released Thursday.
That’s according to the Leapfrog Group, a nonprofit organization known for rating hospitals on patient safety. Leapfrog conducted a voluntary survey of almost 1,800 hospitals to determine how many use computerized-physician-order-entry systems to make sure patients are prescribed and receive the correct drugs, and that medications won’t cause harm.

The takeaway? While a vast majority of hospitals surveyed had some kind of computer-based medication system in place, the systems still fall short in catching possible problems.

“These systems are not always catching the potential errors inherent in prescribing,” said Erica Mobley, Leapfrog’s director of development and communications.

Almost 40 percent of potentially harmful drug orders weren’t flagged as dangerous by the systems, Leapfrog found. These included medication orders for the wrong condition or in the wrong dose based on things like a patient’s size, other illnesses or likely drug interactions.

Meanwhile, systems missed about 13 percent of errors that could have killed patients.

According to 2015 figures from the federal Agency for Healthcare Research and Quality, about 1 of every 20 patients in hospitals suffers harm because of medications. Of those, the agency estimates, half are avoidable.

Meanwhile, in a push to improve patient safety and health care quality, the federal government has been encouraging hospitals to adopt electronic health records — particularly with medication ordering systems — thanks to parts of the 2009 stimulus package and 2010 health reform. But there’s been pushback from many doctors and advocates, who say design issues can make the software difficult to use or even counterproductive.

The Leapfrog survey — which is not peer-reviewed — asked participating hospitals to use “dummy patients” to test their system, Mobley said. Participants would put in information for fake patients and submit a set of medication orders to see which ones got flagged. Mistakes might include orders prescribing an adult dosage to a child, for instance.

The results are “alarming,” said Helen Haskell, a prominent patient safety advocate. “It shows that the technology is not as foolproof as we would like to think.”

But it’s difficult to know how many of those missed errors result in actual harm, Mobley acknowledged. Ordering the wrong medication can be inconvenient or problematic. But it isn’t always dangerous. And, for those that are, hospitals may have other safeguards in place to catch mistakes before they actually hurt patients. “It really does vary significantly by hospital,” she said.

The survey, Mobley suggested, underscores the need for hospitals and patients to be vigilant when it comes to overseeing their medications. For hospitals, that means instituting “checks and balances” — system-wide initiatives like requiring manual reviews of a patient’s drugs, on top of the computer checks.

And hospitals are increasingly taking such steps to make medication errors less common, said Jesse Pines, who directs the Office for Clinical Practice Innovation at George Washington University and is a professor of emergency medicine. Technology is also improving, so medication ordering systems should get better, he added.

“Technology exists to help with detecting medical errors at the point of when you’re entering drug orders in the hospital or health care settings,” he said. “But they’re not perfect. They still need a lot of work.”

Patients, meanwhile, should make sure to have someone with them when they go into the hospital, who can check out what drugs they’re being prescribed, Mobley said.

“It’s absolutely critical that whenever the patient or somebody with them notices that this maze [of medications] looks slightly different from what’s been done in the past, they ask about that,” she said.

But even with that vigilance, Haskell said, “your knowledge is not infinite — so there’s a limit to what patients can do.”

Hospitals can try to customize their medication ordering systems to do things like identify frequently ordered drugs or better match the patients they’re likely to treat.

How well they do at adapting the software can also play a role in how good hospitals are at catching and preventing mistakes when it comes to ordering medications, said Raj Ratwani, who researches health care safety and is the scientific director for MedStar Health’s National Center for Human Factors in Healthcare in Washington, D.C. To that end, hospitals and safety experts should figure out what are the best practices when it comes to customizing tools like medication ordering software.

A number of Leapfrog’s surveys have come under scrutinyfrom some hospitals, who question their methodology and metrics. Here, Mobley said, the survey may inflate the number of hospitals with a computer-based medication ordering system. But when it comes to how effective the systems are, the findings are unsurprising, both Haskell and Ratwani said.

“What these findings indicate — and what many other researchers have shown — is that computerized physician order entry is effective at reducing adverse drug events,” Ratwani said. “What we also know … is these electronic health record systems are complex.”


Kaiser Health News (KHN) is a nonprofit national health policy news service.