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American Journal of Health-System Pharmacy, Vol. 66, Issue 12, 1119-1124
Copyright © 2009. American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/04/0602-1242$06.00

Medication-Use Technology

Evaluation of causes and frequency of medication errors during information technology downtime

 Tara L. Hanuscak, Sheryl L. Szeinbach, Enrique Seoane-Vazquez, Brendan J. Reichert and Charles F. McCluskey

TARA L. HANUSCAK, PHARM.D., M.S., is Business Manager, Pharmacy Services, Riverside Methodist Hospital, Columbus, OH. At the time of writing, she was Resident, Riverside Methodist Hospital. SHERYL L. SZEINBACH, PH.D., M.S., B.S. PHARM., is Professor, Division of Pharmacy Practice and Administration, College of Pharmacy, The Ohio State University, Columbus. ENRIQUE SEOANE-VAZQUEZ, PH.D., is Assistant Professor, Division of Pharmacy Practice and Administration, College of Pharmacy, The Ohio State University; and Scholar, Center for Health Outcomes, Policy and Evaluation Studies, College of Public Health, The Ohio State University. BRENDAN J. REICHERT, M.S., B.S. PHARM, is Assistant Director, MedUse Informatics, Johns Hopkins Hospital, Baltimore, MD. At the time of writing, he was Clinical Applications Manager, Riverside Methodist Hospital. CHARLES F. MCCLUSKEY, PHARM.D., is Director of Pharmacy, Riverside Methodist Hospital.

Address correspondence to Dr. Szeinbach at the Division of Pharmacy Practice and Administration, College of Pharmacy, The Ohio State University, Columbus, OH 43201 (szeinbach.1{at}osu.edu).


Purpose. The causes and frequency of medication errors occurring during information technology downtime were evaluated.

Methods. Individuals from a convenience sample of 78 hospitals who were directly responsible for supporting and maintaining clinical information systems (CISs) and automated dispensing systems (ADSs) were surveyed using an online tool between February 2007 and May 2007 to determine if medication errors were reported during periods of system downtime. The errors were classified using the National Coordinating Council for Medication Error Reporting and Prevention severity scoring index. The percentage of respondents reporting downtime was estimated.

Results. Of the 78 eligible hospitals, 32 respondents with CIS and ADS responsibilities completed the online survey for a response rate of 41%. For computerized prescriber order entry, patch installations and system upgrades caused an average downtime of 57% over a 12-month period. Lost interface and interface malfunction were reported for centralized and decentralized ADSs, with an average downtime response of 34% and 29%, respectively. The average downtime response was 31% for software malfunctions linked to clinical decision-support systems. Although patient harm did not result from 30 (54%) medication errors, the potential for harm was present for 9 (16%) of these errors.

Conclusion. Medication errors occurred during CIS and ADS downtime despite the availability of backup systems and standard protocols to handle periods of system downtime. Efforts should be directed to reduce the frequency and length of down-time in order to minimize medication errors during such downtime.

Index terms: Automation; Computers; Data collection; Drug distribution systems; Errors, medication; Hospitals; Information; Medication orders; Pharmacy, institutional, hospital; Technology

 

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