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An Analysis of the Safety of Medication Ordering Using Typo Correction within an Academic Medical SystemFunding None.
Objectives Spelling during medication ordering is prone to error, which can contribute to frustration, confusion, and, ultimately, errors. Typo correction can be utilized in an effort to mitigate the effects of misspellings by providing results even when no exact matches can be found. Although, typo correction can be beneficial in some scenarios, safety concerns have been raised when utilizing the functionality for medication ordering. Our primary objective was to analyze the effects of typo correction technology on medication errors within an academic medical system after implementation of the technology. Our secondary objective was to identify and provide additional recommendations to further improve the safety of the functionality.
Methods We analyzed 8 months of post-implementation data obtained from staff-reported medication errors and search query information obtained from the electronic health record. The reports were analyzed by two pharmacists in two phases: retrospective identification of errors occurring as a result of typo correction and prospective identification of potential errors with continued use of the functionality.
Results In retrospective review of 2,603 reported medication-related errors, 26 were identified as potentially involving typo correction as a contributing factor. Six of these orders invoked typo correction, but none of the errors could be attributed to typo correction. In prospective review, a list of 40 error-prone words and terms were identified to be added as stop words and 407 medication synonyms were identified for removal from their associated medication records.
Conclusion Our results indicate, when properly implemented, typo correction does not cause additional medication errors. However, there may be benefit in implementing further precautions for preventing future errors.
Protection of Human and Animal Subjects
Human and/or animal subjects were not included in the project
* Dr Darby's current affiliation is Cleveland Clinic, Cleveland, Ohio, United States.
Received: 22 February 2021
Accepted: 31 May 2021
Article published online:
02 August 2021
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- 1 Kuperman GJ, Bobb A, Payne TH. et al. Medication-related clinical decision support in computerized provider order entry systems: a review. J Am Med Inform Assoc 2007; 14 (01) 29-40
- 2 Cutler DM, Feldman NE, Horwitz JR. U.S. adoption of computerized physician order entry systems. Health Aff (Millwood) 2005; 24 (06) 1654-1663
- 3 Novak LL, Anders S, Unertl KM, France DJ, Weinger MB. Improving the effectiveness of health information technology: the case for situational analytics. Appl Clin Inform 2019; 10 (04) 771-776
- 4 Koppel R, Metlay JP, Cohen A. et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA 2005; 293 (10) 1197-1203
- 5 About Medication Errors. NCC MERP. Published January 30, 2015. Accessed April 10, 2021 at: https://www.nccmerp.org/about-medication-errors#:~:text=%22A%20medication%20error%20is%20any%20preventable%20event%20that,of%20the%20health%20care%20professional%2C%20patient%2C%20or%20consumer
- 6 Alqenae FA, Steinke D, Keers RN. Prevalence and nature of medication errors and medication-related harm following discharge from hospital to community settings: a systematic review. Drug Saf 2020; 43 (06) 517-537
- 7 Abraham J, Galanter WL, Touchette D. et al. Risk factors associated with medication ordering errors. J Am Med Inform Assoc 2021; 28 (01) 86-94
- 8 Garber A, Nowacki AS, Chaitoff A. et al. Frequency, timing, and types of medication ordering errors made by residents in the electronic medical records era. South Med J 2019; 112 (01) 25-31
- 9 Abraham J, Kannampallil TG, Jarman A. et al. Reasons for computerised provider order entry (CPOE)-based inpatient medication ordering errors: an observational study of voided orders. BMJ Qual Saf 2018; 27 (04) 299-307
- 10 Soualmia LF, Prieur-Gaston E, Moalla Z, Lecroq T, Darmoni SJ. Matching health information seekers' queries to medical terms. BMC Bioinformatics 2012; 13 (Suppl. 14) S11
- 11 Ferner RE, Aronson JK. Nominal ISOMERs (Incorrect Spellings Of Medicines Eluding Researchers)-variants in the spellings of drug names in PubMed: a database review. BMJ 2016; 355: i4854
- 12 Epic Systems Corporation. Did You Mean: Order Search Setup and Support Guide. Epic Galaxy. Published May 1, 2020. Accessed May 26, 2020 at: https://galaxy.epic.com/Redirect.aspx?DocumentID=100022569
- 13 Computerized prescriber order entry medication safety (CPOEMS): Uncovering and learning from issues and errors. Accessed April 10, 2021 at: https://www.fda.gov/media/95234/download
- 14 Zhou L, Mahoney LM, Shakurova A. et al. How many medication orders are entered through free-text in EHRs?—a study on hypoglycemic agents. AMIA Annu Symp Proc 2012; 2012: 1079-1088
- 15 Sarker A, Gonzalez-Hernandez G. An unsupervised and customizable misspelling generator for mining noisy health-related text sources. J Biomed Inform 2018; 88: 98-107
- 16 Grabar N, Zweigenbaum P, Soualmia L, Darmoni S. Matching controlled vocabulary words. Stud Health Technol Inform 2003; 95: 445-450
- 17 Institute for Safe Medication Practices. Safety brief: For medication orders, “fuzzy matching” is fuzzy illogical. ISMP Medication Safety Alert!. Acute Care 2019; 24 (02) 1-3
- 18 Institute for Safe Medication Practices. Safety brief: more on fuzzy matching. ISMP Medication Safety Alert!. Acute Care 2019; 24 (03) 4-5
- 19 Bryan R, Aronson JK, Williams A, Jordan S. The problem of look-alike, sound-alike name errors: drivers and solutions. Br J Clin Pharmacol 2021; 87 (02) 386-394
- 20 2020 Report to the Community. Accessed April 10, 2021 at: https://www.froedtert.com/sites/default/files/upload/docs/about/report-to-the-community.pdf
- 21 CMS. State Operations Manual Appendix a—survey protocol, regulations and interpretive guidelines for hospitals transmittals for Appendix A. 2015 . Accessed April 10, 2021 at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf