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JOHN P. SANTELL, M.S., FASHP, is Director of Pharmacopeial Education, United States Pharmacopeia (USP), Rockville, MD. JOANNE G. KOWIATEK, M.P.M., is Pharmacy Manager, Pharmacy Administration, University of Pittsburgh Medical Center Presbyterian Hospital, Pittsburgh, PA. ROBERT J. WEBER, M.S., FASHP, is Associate Professor and Chairman, Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh. RODNEY W. HICKS, PH.D., ARNP, is Endowed Chair, Patient Safety, and Professor, School of Nursing, Texas Tech University Health Sciences Center, Lubbock; at the time of writing, he was Research Manager, Center for Advancement of Patient Safety, USP. CARL A. SIRIO, M.D., is Associate Professor, Critical Care Medicine, Medicine and Pharmacy and Therapeutics, University of Pittsburgh Schools of Medicine and Pharmacy.

Address correspondence to Mr. Santell at the Department of Pharmacopeial Education, United States Pharmacopeia, 12601 Twinbrook Parkway, Rockville, MD 20852 (jps{at}usp.org).

Purpose. The characteristics of medication errors associated with the use of computer order-entry systems by nonprescribers are discussed. Methods. A retrospective analysis of records submitted to MEDMARX was conducted for the period from July 1, 2001, to December 31, 2005, to identify all computer-related medication errors made by nonprescribers. Quantitative analysis of the records included the severity of each error, the origin within the medication-use process, the type of error, principal causes, the location within the facility where the error was made, and the therapeutic drug classes frequently involved. Similar data from the University of Pittsburgh Medical Center (UPMC) were also analyzed and compared with the national data set. Results. During the 4.5 years, 693 unique facilities submitted 90,001 medication error records that were the result of computer entry by nonprescribers. The national data set and the UPMC data had similar findings for error severity, error origin, and type of error but showed some differences in the rank ordering of error causes, location where the error occurred, and drug classes frequently associated with such errors. The percentage of harm associated with computer-entry errors was small for both the national data set and UPMC data (0.99% and 0.80%, respectively). Both data sets cited performance deficit as the leading cause of computer-entry errors, but large percentage differences were seen with other causes, including inaccurate or omitted transcription (30% versus 12.6%, respectively), documentation (19.5% versus 10.6%, respectively), and procedure or protocol not followed (21.7% versus 30.3%, respectively). Both data sets implicated the inpatient pharmacy department as the location where most computer-entry errors occurred (49.3% versus 69.0%, respectively). Conclusion. Analysis of the characteristics of medication errors associated with the use of computer-entry systems by non-prescribers from both MEDMARX and an individual health system database demonstrated that computer systems create new opportunities for errors to occur. Working closely with information technology personnel dedicated to assisting pharmacy departments and vendors, adequate training of pharmacy staff, and development of national standards for drug information displays in computer order-entry systems may help minimize such errors. Index terms: Computers; Errors, medication; Hospitals; Medication orders