Hospital Uses EMRs to Avoid Drug Errors

HealthLeaders Media Staff, August 31, 2009

In 2008, Linda Severson, RN, was called into her superintendent's office after the facility had experienced a near miss pertaining to look-alike/sound-alike drugs. He asked her if there was anything she could do to prevent this kind of problem from happening again.

In response, Severson, who works at Cherokee Mental Health Institute (CMHI), in Cherokee, IA,  took matters into her own hands and changed the CMHI computer system settings for all look-alike/sound-alike drugs so that they show up differently than the rest by default. This change brings additional attention to look-alike/sound-alike drugs to the person entering the record.

Since implementing the new process, CMHI has seen and is now tracking a noticeable reduction in errors associated with look-alike/sound-alike drugs.

Electronic medical records
The facility's original medical record system was used as an order entry form. For example, if the practitioner filling out the form worked in pharmacy, he or she would identify pharmacy in the order type. Then the order code would be brought up, which in pharmacy's case, would be the particular type of drug.

When it came time for the pharmacy practitioner to choose the type of drug, this was where CMHI experienced problems.

One particular case was distinguishing between the drug hydroxyzine, an antihistamine used to treat insomnia, and hydralazine, an anti-hypertensive drug used to treat high blood pressure.

"When you chose the drug, you would only have to put a portion of the drug name in," says Severson. "When you typed in [the letters] 'HYDR,' you would get every drug with those four letters in it."

Picking the right list and defaults
Severson went to The Joint Commission's Web site for a list of all the look-alike/sound-alike drugs. She then took this list to CMHI physicians and asked them to come up with a common list she could default into the computer system.

With the help of the practitioners, Severson developed a list of 42 look-alike/sound-alike drugs to be programmed and defaulted into the CMHI computer system.

"It would have been ideal if the system had a little bell that would ding or something," says Severson on making look-alike/sound-alike drugs distinguishable from the rest. Instead, Severson alternated capitalization on each of the 42 pre-determined drugs.

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