Medication errors: prevention using information technology systems

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This is a systematic review of the article entitled “Medication errors: prevention using information technology systems” by Abha Agrawal [1]


  • The authors of the article observed that medication error prevention has become a top priority for health systems globally due to the high incidence of medication errors which results in subsequent patient injury and unexpected costs.
  • They also evaluated the increasing amount of evidence supporting extensive implementation of information technology tools.
  • It was determined that the use of information technology tools such as computerized physician order entry (CPOE), automated dispensing machines, barcode medication administration (BCMA), electronic medication reconciliation, and personal health records are key in preventing medication errors.
  • This article provided an overview of the status of health IT systems in preventing medication errors.


The article revealed that a significant amount of evidence in international scholarly literature document the prevalence of medication errors and adverse drug events. Medication errors were found to be expensive for healthcare systems, clinicians, and to patients and their families. As result, medication error prevention has become a top concern for globally. The authors suggested that health information technology tools such as computerized physician order entry, automated dispensing, barcode medication administration, electronic medication reconciliation, and personal health records are key to preventing medication errors.

The Medication Management Process

The authors described medication management as “complex” and “multifaceted”. A table was created to portray the medication management process, the percent error rate in each step of the medication management process and information technology systems associated with each step.

The article described a typical medication management process as follows:


IT systems relevant to each step in the medication management process were named as follows:

Prescription: CPOE with decision support; Electronic medication reconciliation

Transcription: Automated transcription

Dispensing: Robots, automated dispensing cabinets

Administration: Bar-coding, electronic medication administration

Information Technology Systems in Medication Management

The article emphasized that information systems can help to organize and connect patient information and provide better access for both patients and clinicians.

Computerized physician order entry with decision support

Computerized physician order entry was described as extremely significant because most errors occur during the prescribing phase. The authors determined that CPOE systems work by:

(i). ensuring that the order is readable and complete, including all essential data, such as dose, route, and dosage form;

(ii). checking for complications such as drug allergies and drug–drug interactions;

(iii). providing dosage adjustment calculations based on clinical features such as weight or renal function;

(iv). checking for suitable baseline laboratory results, such as platelet count and international normalized ratio for patients receiving anticoagulants;

(v). computing drug–laboratory interactions, such as warning the prescriber about a low potassium concentration when digoxin is being prescribed;

(vi). informing the prescriber about the newest drug information, such as the need to evade rofecoxib after it had been withdrawn by the manufacturer.

It was found that CPOE systems have had the largest impact on decreasing medication errors, with reported error reductions of 55–83%.

Pharmacy dispensing systems

The authors found dispensing errors to be fairly common and may even go undetected. As a solution, it was pointed out that an assortment of IT systems, such as drug-dispensing robots and automated dispensing cabinets, diminish dispensing errors by packaging, dispensing, and identifying medications using bar codes.

Bar-coded medication administration

The authors explained that BCMA decreases medication errors by making certain that the five ‘rights’ of medication administration: the right patient, drug, dose, route, and time are adhered to. They also explained that a Bar-coded medication administration system calls for the nurse who administers the medication at the bedside to scan the patient's identification bracelet and the unit dose of the medication being administered.

Electronic medication reconciliation

The reconciliation of medication lists during admission, transfer and discharge was described as an essential step in improving safety due to the high number of medication errors occur at care transition points.

Personal Health Records

The authors noted that even though there is no solid evidence yet, advanced Patient Health Records (PHR) can help reduce medication errors. PHR’s offer decision support tools, such as checking for drug allergies and drug–drug interactions and permit patients to foresee potential medication errors and alert physicians to them.

Decision support to reduce medication errors of omission

The article documented the results of a pilot study where the implementation of a ‘smart’ electronic discharge summary that reminds physicians to prescribe medications improved the prescription rate from 88 to 100%.

Concerns and problems

The authors expressed the following concerns about the widespread use of IT systems in health care:

  • Skepticism about evidence regarding the impact of IT system use on clinical outcomes.
  • Potential negative consequences of IT systems on patient safety such as workflow problems.
  • Variations in IT system use outcomes due to inconsistent implementation approaches by clinicians.
  • Poor implementation rate of IT systems by hospitals, clinics and office practices.


In summary, the authors found IT systems critical to preventing medication errors and improving patient safety. However, they noted that there is possibility that these systems could affect clinical workflow negatively. The authors advised that improving standardization and certification and creating an economic and policy environment beneficial to the financial goals of hospitals and physicians would increase IT system adoption rates.


This paper provides an objective overview of the benefits of using health information systems and their associated tools in preventing medication errors. In particular, the article provides simplistic evidence to support the thesis, while also documenting problems and concerns associated with the study. This research would be useful to clinicians looking for information regarding the use of IT systems to prevent medication errors and adverse drug events.

Related Articles

Medication errors: a prospective cohort study of hand-written and computerised physician order entry in the intensive care unit

Impact of a warning CPOE system on the inappropriate pill splitting of prescribed medications in outpatients


  1. Agrawal A. Medication errors: prevention using information technology systems. British Journal of Clinical Pharmacology. 2009;67(6):681-686. doi:10.1111/j.1365-2125.2009.03427.x.