Flash VIG-news: electronic prescription - new types of possible medication errors

The use of electronic prescriptions can lead to new types of medication errors that prescribers should take care to avoid, such as selection errors when using drop-down menus.

According to an article1 published in 2018 in the scientific journal American Journal of Health-System Pharmacy, the use of electronic prescriptions reduces the overall rate of medication errors occurring during prescription, including errors of dosage, posology, frequency, administration route and errors linked to drug-drug interactions. The issue of the legibility of certain handwriting is thus also resolved. However, the use of electronic prescriptions can lead to other kinds of errors such as the incorrect selection of medicinal products from drop-down menus.

The FAMHP was recently challenged by a pharmacist concerning an error that they identified in the dispensary while processing an electronic prescription for Clexane.

The electronic prescription mentioned Clexane© 12000 IU anti-Xa (120 mg)/0.8 ml. The indication was unknown. Having doubts concerning the dosage, the pharmacist contacted the prescriber, who had in fact erroneously selected another more concentrated presentation of the medicinal product (0.8 ml in a syringe) from the drop-down menu. The correspondence of units-mg-ml is correct for ‘small’ dosages (for example 2000 IU - 20 mg - 0.2 ml; 4000 IU - 40 mg - 0.4 ml) but this ceases to be the case for the two most concentrated dosages. Thus, pre-filled 0.8 ml syringes may contain 8000 or 12000 IU, while pre-filled 1 ml syringes may contain 10000 or 15000 IU.
 

In order to reduce this type of error, the FAMHP asks prescribers to be particularly attentive when selecting data from the drop-down menus of IT systems, to remain vigilant when entering data semi-automatically (functions that track recently entered data and offer to reuse it automatically).

If in doubt, for example concerning the nature of the prescribed medicinal product or the recommended dosage, the pharmacist should consult the prescribing doctor.

Actual or potential medication errors, with or without adverse effects, may be notified to the FAMHP, which will assess the cause of the error and, if possible, how to avoid any repetition of this error.

 

1Vélez-Díaz-Pallarés M, Pérez-Menéndez-Conde C, Bermejo-Vicedo T. Systematic review of computerized prescriber order entry and clinical decision support. Am J Health Syst Pharm. 2018 Dec 1;75(23):1909-1921

Last updated on
25/04/2019