Evaluation of medication errors via a computerized physician order entry system in an inpatient renal transplant unit

correspondence: Kwaku Marfo Montefiore-Einstein Center for Transplantation, Department of Pharmacy, Montefiore Medical Center, The University hospital for Albert einstein college of Medicine, 111 east 210th street, Bronx, nY 10467, UsA Tel +1 718 920 3752 Fax +1 718 798 0722 email kmarfo@montefiore.org Background: Medication errors are a prime concern for all in healthcare. As such the use of information technologies in drug prescribing and administration has received considerable attention in recent years, with the hope of improving patient safety. Because of the complexity of drug regimens in renal transplant patients, occurrence of medication errors is inevitable even with a well adopted computerized physician order entering (CPOE) system. Our objective was to quantify medication error type and frequency in an inpatient renal transplant unit. Methods: Systemic evaluation of all medication errors during an initial 10-day audit and a 28-day follow-up audit in an inpatient renal transplant unit. Each error was concurrently evaluated for potential to result in adverse patient consequences (category), error type and associated medication class. Results: A total of 103 clinically significant medication errors were detected during the 10-day (43 errors) and 28-day audit (60 errors) time periods. The most common errors were wrong medication dose ordered and wrong time of drug administration. Thirty-six out of 66 prescribing/ ordering errors reached the patient. Conclusions: Even with utilization of computerized physician order entry system in an inpatient renal transplant unit, post-kidney transplant patients are at risk for adverse outcomes due to medication errors. The risk factors may be multifactorial and will require both organizational and technical approaches to resolve.