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Prescribing potassium despite hyperkalemia: medication errors uncovered by linking laboratory and pharmacy information systems

2000; Elsevier BV; Volume: 109; Issue: 6 Linguagem: Inglês

10.1016/s0002-9343(00)00546-5

1555-7162

Gordon D. Schiff, Hem C Aggarwal, Sanjay Kumar, Robert Mcnutt,

Patient Safety and Medication Errors

Laboratory and pharmacy functions are closely related ( 1 Schiff G.D. Rucker T.D. Computerized prescribing building the electronic infrastructure for better medication usage. JAMA. 1998; 279: 1024-1029 Crossref PubMed Scopus (221) Google Scholar , 2 Firestorm J.J. Grantors P. Iridial K. et al. Linking patient medication data with laboratory information system. Int J Biomed Comput. 1996; 42: 111-116 Abstract Full Text PDF PubMed Scopus (9) Google Scholar , 3 Schentag J.J. The results of a targeted pharmacy intervention program. Clin Ther. 1993; 15: 29-36 PubMed Google Scholar , 4 Gronroos P. Medication and laboratory: a study of computerized monitoring of drug-test and drug-drug interactions in hospital. Turku, Turun Yliopiston Julkaisuja. Annel Universitatis Turkuensis (Turku University Library), Finn 20014, Turku, Finland. 1997;1–57. Google Scholar ). Drug choice and dosing often depend on information such as therapeutic drug levels and biochemical and other physiologic parameters, including renal and hepatic function. Despite this relation between laboratory and pharmacy, connections between these two disciplines and their information systems are often suboptimal or nonexistent ( 1 Schiff G.D. Rucker T.D. Computerized prescribing building the electronic infrastructure for better medication usage. JAMA. 1998; 279: 1024-1029 Crossref PubMed Scopus (221) Google Scholar , 5 Lundberg G.D. The need for an outcomes research agenda for clinical laboratory testing. JAMA. 1998; 280: 565-566 Crossref PubMed Scopus (88) Google Scholar , 6 Bates D.W. O’Neil A.C. Boyle D. et al. Potential identifiability and preventability of adverse events using information systems. J Am Med Inform Assoc. 1994; 1: 404-411 Crossref PubMed Scopus (118) Google Scholar ). Few hospitals, and even fewer outpatient systems, have pharmacy computers linked to laboratory data. As a result, there is potential for errors due to failure to modify prescribing in response to laboratory results ( 6 Bates D.W. O’Neil A.C. Boyle D. et al. Potential identifiability and preventability of adverse events using information systems. J Am Med Inform Assoc. 1994; 1: 404-411 Crossref PubMed Scopus (118) Google Scholar , 7 Rind D.M. Safran C. Phillips R.S. et al. Effect of computer-based alerts on the treatment and outcomes of hospitalized patients. Arch Intern Med. 1994; 154: 1511-1517 Crossref PubMed Scopus (246) Google Scholar , 8 Kuperman G.J. Boyle D. Jha A. et al. How promptly are inpatients treated for critical laboratory results?. J Am Med Inform Assoc. 1998; 5: 112-119 Crossref PubMed Scopus (68) Google Scholar , 9 Leape L.L. Error in medicine. JAMA. 1994; 272: 1851-1857 Crossref PubMed Google Scholar , 10 Bates D.W. Leape L.L. Cullen D.J. et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998; 280: 1311-1316 Crossref PubMed Scopus (1680) Google Scholar ).