PHARMACY CONNECTION ARTICLE

Focus on Error Prevention: Computerized Physician Order Entry (CPOE)

Published on: February 1, 2013 fax and printer prescription

Ian Stewart B.Sc.Phm., R.Ph

The misinterpretation of handwritten prescriptions is a common source of medication errors. However, the increase in use of computer generated prescriptions is a positive step in the prevention of errors caused by illegible handwriting.

With the introduction of this new technology, pharmacists must be aware of the potential for new types of errors. Errors seen with computerized physician order entry (CPOE) include: omission of key information, inappropriate abbreviation, conflicting information, selection of an incorrect drug from a drop down menu, etc.

Case:

Rx
Medication: pantoprazole magnesium 40mg tablet
Sig: 1 tablet two times daily
Quantity: 180 tablets
Limited Use code: 293

The above prescription was computer generated, signed and given to a 75 year old patient. The prescription was taken to a local community pharmacy for processing. The pharmacy assistant noticed that the patient was over sixty five years old and therefore covered by the Ontario Drug Benefit Program. She also noticed that the prescriber included a Limited Use code of 293 which is a “reason for use code” for Pantoloc®. The prescription was therefore entered as Apo-Pantoprazole® 40mg tablets.

On checking the prescription, the pharmacist noticed that Apo-Pantoprazole® was pantoprazole sodium and not pantoprazole magnesium as prescribed. The prescription was therefore cancelled and dispensed as pantoprazole magnesium (Tecta®).

Approximately three months later, the patient requested a refill of the Tecta® tablets. On contacting the prescriber for authorization to dispense the medication, he stated that he did not prescribe Tecta® initially. Following an investigation, the error was discovered and the details discussed with the physician.

TABLE 1

Pantoprazole sodiumPantoprazole magnesium
Diclofenac potassiumDiclofenac sodium
Hydrocortisone (Emo-Cort®)Hydrocortisone acetate (Hyderm®)
Morphine sulphateMorphine HCL
Docusate sodiumDocusate calcium
Testosterone cypionateTestosterone enanthate

Possible Contributing factors:

  • The computer generated prescription included conflicting information. The physician prescribed pantoprazole magnesium (Tecta®), but provided the Limited Use code for pantoprazole sodium (Pantoloc®).
  • The pharmacist did not contact the prescriber to clarify the ambiguous information.
  • The physician likely selected pantoprazole magnesium from a drop down menu instead of pantoprazole sodium as he had intended to prescribe.

Recommendations:

  • Though computer generated prescriptions can minimize medication errors due to illegible handwriting, be aware that new types of errors may be introduced.
  • Always contact the prescriber to clarify ambiguous prescriptions.
  • Become familiar with drugs that are available in different forms that are not interchangeable. Examples are included in Table 1

Please continue to send reports of medication errors in confidence to:
Ian Stewart at: [email protected]

Please ensure that all identifying information (e.g. patient name, pharmacy name, healthcare provider name, etc.) are removed before submitting.

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