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E-Prescription Errors and Their Resolution in a Community Compounding Pharmacy

Author(s):  Reed-Kane Dana, Vasquez Kellie, Pavlik Aaron, Pergine Johanna, Sandberg Michelle

Issue:  Mar/Apr 2014 - Volume 18, Number 2
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Abstract:  Despite apparent benefits, electronic prescribing systems still face numerous challenges. Errors associated with electronic prescriptions can often lead to workflow disruptions. This may be particularly disruptive in smaller, independent community pharmacies that may not have the staffing resources to adequately cope with an increase in required correspondence with prescriber offices. The objective of this study was to follow-up on a 2012 quality-improvement project evaluating electronic prescription error type, error rate, and time between error discovery and resolution in an independent compounding pharmacy. The study design was quality improvement with descriptive data. Data were collected over a four-week period during which time the pharmacists completed a data collection form for each electronic prescription received that contained an error. Percentages were calculated for error type, error rate, and error resolution type. Using range, mean, and standard deviation, time until error resolution was reported. In the four-week study period an e-prescribing error rate of 23.2% was identified (32 errors identified in 138 e-prescriptions). The most frequent error was an invalid electronic prescription signature for a controlled substance (31.3%, n=10). The most commonly used error resolution method was a phone call to the physician (59%, n=19). The average time to resolve the most frequent error type was 10.30 hours with a standard deviation of 18.18 hours. The results show a 40% decrease in the number of e-prescription errors identified compared to the quality-improvement evaluation done in the same pharmacy one year ago. E-prescription errors continue to disrupt workflow and impede patient care but perhaps at a lower rate. Pharmacies should implement a quality-improvement review process to help identify solutions to systems issues.

Related Keywords: Diana Reed-Kane, PharmD, FIACP, FACA, NFPPhC, FCP, Kellie Vasquez, Aaron Pavlik, Johanna Peragine, Michelle Sandberg, electronic prescribing, e-prescription, prescription errors, medication errors, community pharmacy, quality improvement


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