Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, University of New South Wales, Sydney, Australia.
PLoS Med. 2012 Jan;9(1):e1001164. doi: 10.1371/journal.pmed.1001164. Epub 2012 Jan 31.
Considerable investments are being made in commercial electronic prescribing systems (e-prescribing) in many countries. Few studies have measured or evaluated their effectiveness at reducing prescribing error rates, and interactions between system design and errors are not well understood, despite increasing concerns regarding new errors associated with system use. This study evaluated the effectiveness of two commercial e-prescribing systems in reducing prescribing error rates and their propensities for introducing new types of error.
We conducted a before and after study involving medication chart audit of 3,291 admissions (1,923 at baseline and 1,368 post e-prescribing system) at two Australian teaching hospitals. In Hospital A, the Cerner Millennium e-prescribing system was implemented on one ward, and three wards, which did not receive the e-prescribing system, acted as controls. In Hospital B, the iSoft MedChart system was implemented on two wards and we compared before and after error rates. Procedural (e.g., unclear and incomplete prescribing orders) and clinical (e.g., wrong dose, wrong drug) errors were identified. Prescribing error rates per admission and per 100 patient days; rates of serious errors (5-point severity scale, those ≥3 were categorised as serious) by hospital and study period; and rates and categories of postintervention "system-related" errors (where system functionality or design contributed to the error) were calculated. Use of an e-prescribing system was associated with a statistically significant reduction in error rates in all three intervention wards (respectively reductions of 66.1% [95% CI 53.9%-78.3%]; 57.5% [33.8%-81.2%]; and 60.5% [48.5%-72.4%]). The use of the system resulted in a decline in errors at Hospital A from 6.25 per admission (95% CI 5.23-7.28) to 2.12 (95% CI 1.71-2.54; p<0.0001) and at Hospital B from 3.62 (95% CI 3.30-3.93) to 1.46 (95% CI 1.20-1.73; p<0.0001). This decrease was driven by a large reduction in unclear, illegal, and incomplete orders. The Hospital A control wards experienced no significant change (respectively -12.8% [95% CI -41.1% to 15.5%]; -11.3% [-40.1% to 17.5%]; -20.1% [-52.2% to 12.4%]). There was limited change in clinical error rates, but serious errors decreased by 44% (0.25 per admission to 0.14; p = 0.0002) across the intervention wards compared to the control wards (17% reduction; 0.30-0.25; p = 0.40). Both hospitals experienced system-related errors (0.73 and 0.51 per admission), which accounted for 35% of postsystem errors in the intervention wards; each system was associated with different types of system-related errors.
Implementation of these commercial e-prescribing systems resulted in statistically significant reductions in prescribing error rates. Reductions in clinical errors were limited in the absence of substantial decision support, but a statistically significant decline in serious errors was observed. System-related errors require close attention as they are frequent, but are potentially remediable by system redesign and user training. Limitations included a lack of control wards at Hospital B and an inability to randomize wards to the intervention.
许多国家都在商业电子处方系统（e-prescribing）上投入了大量资金。很少有研究测量或评估它们在降低处方错误率方面的有效性，尽管人们越来越关注与系统使用相关的新错误，但系统设计和错误之间的相互作用仍未得到很好的理解。本研究评估了两种商业电子处方系统在降低处方错误率及其引入新类型错误的倾向方面的有效性。
我们进行了一项前后对照研究，对澳大利亚两所教学医院的 3291 例入院患者进行了用药图表审核（基线时 1923 例，实施电子处方系统后 1368 例）。在医院 A，Cerner Millennium 电子处方系统在一个病房实施，另外三个没有实施电子处方系统的病房作为对照。在医院 B，iSoft MedChart 系统在两个病房实施，我们比较了前后的错误率。确定了程序（例如，不明确和不完整的处方医嘱）和临床（例如，错误的剂量、错误的药物）错误。计算了每个入院和每 100 个患者日的处方错误率；按医院和研究期间计算严重错误（5 分严重程度量表，≥3 分为严重）的发生率；以及干预后“系统相关”错误（系统功能或设计导致错误）的发生率和类别。在所有三个干预病房中，使用电子处方系统与错误率的显著降低相关（分别降低 66.1%[95%CI 53.9%-78.3%]；57.5%[33.8%-81.2%]；60.5%[48.5%-72.4%]）。系统的使用导致医院 A 的错误率从每入院 6.25 例（95%CI 5.23-7.28）降至 2.12 例（95%CI 1.71-2.54；p<0.0001），医院 B 从每入院 3.62 例（95%CI 3.30-3.93）降至 1.46 例（95%CI 1.20-1.73；p<0.0001）。这一下降主要是由于不明确、非法和不完整的医嘱大量减少。医院 A 的对照病房没有出现显著变化（分别为-12.8%[95%CI-41.1%至 15.5%]；-11.3%[-40.1%至 17.5%]；-20.1%[-52.2%至 12.4%]）。临床错误率变化有限，但干预病房与对照病房相比，严重错误减少了 44%（从每入院 0.25 降至 0.14；p=0.0002）（17%的降幅；0.30-0.25；p=0.40）。两家医院都发生了系统相关错误（每入院 0.73 和 0.51 例），占干预病房系统后错误的 35%；每个系统都与不同类型的系统相关错误相关。
实施这些商业电子处方系统导致处方错误率显著降低。在缺乏实质性决策支持的情况下，临床错误的减少是有限的，但严重错误的显著下降是观察到的。系统相关错误需要密切关注，因为它们很频繁，但可以通过系统重新设计和用户培训来纠正。研究的局限性包括医院 B 缺乏对照病房，以及无法对病房进行随机分组干预。
