Devine Emily Beth, Wilson-Norton Jennifer L, Lawless Nathan M, Hansen Ryan N, Hazlet Thomas K, Kelly Kerry, Hollingworth William, Blough David K, Sullivan Sean D
Department of Pharmacy, University of Washington (UW), Seattle, WA 98195-7630, USA.
Am J Health Syst Pharm. 2007 May 15;64(10):1062-70. doi: 10.2146/ajhp060125.
A pilot study was conducted to characterize the epidemiology of prescribing errors, comparing those that occurred pre- to postimplementation of an electronic prescribing system; this article describes the results of the study during the preimplementation phase, when a handwritten prescription process was still in place.
A retrospective review of 1411 prescriptions that were handwritten during a five-month time frame was used to identify and characterize medication errors and potential medication errors. The review was conducted in an internal medicine clinic in a large health system that was preparing to implement an electronic prescribing system. The first phase was the implementation of a basic system-one that facilitated the writing of a more complete and legible prescription. The second phase consisted of adding more sophisticated clinical decision support (CDS) capabilities. Three data sources were reviewed: the handwritten prescription, the electronic health record and the prescription as it had been entered into the pharmacy computer system. Almost 28% of the prescriptions evaluated contained one or more errors or potential errors. Over 90% of the errors were potential errors. Only 0.2% of the errors caused patient harm. Non-clinical errors (illegibility, missing information, wrong dose) may be affected by a basic electronic prescribing system, and clinical errors (drug-disease interaction, contraindication of a drug) may be affected only when more sophisticated levels of CDS programming are added.
Potential prescribing errors occurred frequently but few reached the patient or caused harm. The most severe errors were those that may be reduced by the implementation of an electronic prescribing system with CDS capabilities.
开展一项试点研究以描述处方错误的流行病学特征，比较电子处方系统实施前后发生的处方错误；本文描述了在实施前阶段（当时仍采用手写处方流程）的研究结果。
对在五个月时间内手写的1411份处方进行回顾性审查，以识别和描述用药错误及潜在用药错误。审查在一家大型医疗系统的内科诊所进行，该诊所正准备实施电子处方系统。第一阶段是实施一个基本系统，该系统有助于书写更完整、清晰的处方。第二阶段包括增加更复杂的临床决策支持（CDS）功能。审查了三个数据源：手写处方、电子健康记录以及录入药房计算机系统的处方。近28%的评估处方包含一个或多个错误或潜在错误。超过90%的错误是潜在错误。只有0.2%的错误对患者造成伤害。非临床错误（字迹潦草、信息缺失、剂量错误）可能会受到基本电子处方系统的影响，而临床错误（药物 - 疾病相互作用、药物禁忌）只有在添加更复杂级别的CDS程序时才可能受到影响。
潜在处方错误频繁发生，但很少影响到患者或造成伤害。最严重的错误可能会通过实施具有CDS功能的电子处方系统而减少。
