Our study is the first to our knowledge to quantitatively evaluate the effect on ambulatory prescribing errors of transitioning between e-prescribing systems. Implementation of the new, commercial system led to a significant and progressive decrease in overall rates of prescribing errors, largely by reducing inappropriate abbreviations.
Rates for non-abbreviation prescribing errors, however, were actually highest at 12 weeks post-implementation, suggesting that transitioning between systems may pose potential patient safety threats even for experienced e-prescribers. Previous studies have identified unintended negative consequences from the introduction and use of computerized systems for ordering medications, including the facilitation of errors36,37
. Also in our study, overall error rates for non-abbreviation errors were no different at one year and baseline, despite the fact that the old system had very limited CDS, although due to our small sample size, we may not have been able to detect a significant difference. This is despite a low overall prescribing error rates for non-abbreviation errors compared to rates in other published studies using identical methodology7,13
One of the major perceived safety benefits of e-prescribing is CDS to aid with medication ordering38
. However, the value of CDS is often limited by providers’ lack of alert acceptance. Multiple studies have shown that providers frequently override alerts because they are perceived as irrelevant39–42
. The inability of EHR systems to effectively present information for CDS purposes may contribute to the mixed safety benefits observed in studies1,7–10,12,13
. In our study, for example, the newer system generated two alerts at separate steps in the ordering process to target inappropriate abbreviations. While this led to an immediate reduction in inappropriate abbreviation use, inappropriate abbreviation errors still constituted the majority of prescribing errors, suggesting that the content or the presentation of the alerts had limited effectiveness in modifying prescribing behavior.
In a companion qualitative study that we did with the providers, findings from semi-structured interviews and field observations complement findings in this manuscript35
. We found that almost all providers, even though they were experienced e-prescribers, considered the transition difficult. Consistent with our survey findings, most physicians did not view the newer system as improving safety, despite more CDS features, and alert fatigue led to routine overriding of alerts.
Studying the types and frequencies of errors made using e-prescribing systems can allow for targeted improvements in system design, CDS presentation, and implementation. For example, the second most common error we detected was directions errors. Pre-printed templates with clear patient instructions may help eliminate these errors. By determining drug classes most frequently involved in errors, CDS can be developed specifically to reduce these errors. Targeted alerts for certain prescribing errors have been shown to be effective8–10
. In addition, it can also guide calibration of CDS such that there is a higher sensitivity to trigger alerts. Importantly, although the majority of the prescribing errors we detected lacked potential to cause serious harm, these errors can result in inefficiencies (such as pharmacy callbacks) and thus are important to study. Research has shown that pharmacy callbacks are common and often lead to delays in medication dispensing that pose threats to patient safety43
Our study has several limitations. Providers were not blinded to the study’s purpose and may have been extra careful when prescribing, making our results conservative estimates of true error rates. We were also limited by our methodology to comment on near misses and preventable ADEs. However, given previous research demonstrating that 4% of patients experience a preventable ADE, it is likely that near misses and preventable ADEs occurred that we were unable to capture7
. Additionally, because we were unable to ascertain from electronic downloads whether the older system automatically corrected inappropriate abbreviations, we may have overestimated these errors at baseline.
Our study was conducted in one clinic, limiting generalizability. We studied only two systems, although the commercial system is widely utilized and incorporates many features recommended by an expert panel44
. We also did not observe providers using both systems, nor do we have data logs tracking the frequency with which alerts were generated or over-ridden. Thus, our ability to comment on usage and usability of the systems is limited and can be derived only from survey data. Finally, due to the small sample sizes for non-abbreviation prescribing errors, we are limited in our ability to detect differences in error rates at different time periods. Future studies should be performed with more providers, multiple systems, and at diverse sites. Longitudinal studies should also be conducted to determine how error rates change over time as iterative refinements are made and providers become more familiar with a new system.
With federal incentives promoting meaningful use of certified EHRs, more organizations will likely transition between e-prescribing systems. Our results suggest that transitioning may lead to unintended negative patient safety consequences, particularly early post-transition. This is despite strategies such as pre-transferring medication data between systems, requiring providers to attend mandatory training sessions, and providing on-site support during and after go-live. Additional strategies may therefore be needed to make transitioning safer. For example, providers may need more individualized training and closer follow-up to address prescribing errors in a timelier manner.
Our study also suggests that organizations and vendors may have to better tailor the design and configuration of CDS to achieve greater safety gains. Focusing CDS toward certain types of errors, such as inappropriate abbreviation errors, may be one such strategy. Greater provider education on rates and types of prescribing errors will complement this strategy. Finally, given the rapidly evolving nature of e-prescribing adoption on a national level and the potential safety issues that may arise, it will be important for organizations to monitor safety issues and iteratively refine systems to ensure that adoption actually leads to safer healthcare delivery.