Computer systems fail to find drug errors

Only four of 307 hospitals that participated in a test of pharmacy computer systems detected 10 of 10 specific, lethal medication orders, according to the Institute for Safe Medication Practices.

The Martinsdale, PA-based nonprofit organization tested the hospitals on lethal medication orders that were reported to the U.S. Pharmacopoeia Medication Errors Reporting Program in 1998. Although some hospitals detected many potential problems, an overwhelming number failed on at least one count.

"It's frightening to believe that the vast majority of our nation's pharmacy computer systems currently may be incapable of preventing these lethal errors," said Michael Cohen, cofounder of the Institute.

According to the Institute's survey, 87% of the tested computer systems failed to detect toxic doses of antibiotics for patients with renal impairment. Similarly, 87% failed to detect single or cumulative lethal doses of colchicine, a drug used for gout.

Sixty-five percent of the pharmacy systems did not detect potentially toxic drug ingredient duplication with acetaminophen and Percocet,® which contains acetaminophen; more than 60% failed to find lethal overdoses of the cancer drugs cisplatin or vincristine; 61% did not raise an alert when an oral suspension was ordered for intravenous use; and 58% of the systems did not link the pharmacy to the hospital laboratory so that they could share vital information.

Despite these shortcomings, the Institute noted that many of the systems can be programmed to improve drug interaction warnings. Almost 70% of those who participated in the test said their systems allowed them to program specific medication alerts based on drug information updates and error alerts.

However, computers are only as smart as their programmers tell them to be, and only 54% of test participants said they receive and integrate drug information updates into their systems on at least a quarterly basis. Another 8% said they never integrate the information. Three percent claimed they never receive the information at all.

The Institute of Safe Medication Practices recommended that hospital pharmacies seek out drug information alerts, build error alerts into existing computer screening programs and avoid sole reliance on computer screening for the detection of prescription drug errors. PR