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David W. Bates, MD; Lucian L. Leape, MD; David J. Cullen, MD; Nan Laird, MD; Laura A. Petersen, MD; Jonathan M. Teich, MD, PhD; Elizabeth Burdick, MS; Mairead Hickey, MD; Sharon Kleefield, MD; Brian Shea, MD; Martha Vander Vliet, RN; Diane L. Seger, RPh

JAMA. 1998;280:1311-1316.

Context.— Adverse drug events (ADEs) are a significant and costly cause of injury during hospitalization.

Objectives.— To evaluate the efficacy of 2 interventions for preventing nonintercepted serious medication errors, defined as those that either resulted in or had potential to result in an ADE and were not intercepted before reaching the patient.

Design.— Before-after comparison between phase 1 (baseline) and phase 2 (after intervention was implemented) and, within phase 2, a randomized comparison between physican computer order entry (POE) and the combination of POE plus a team intervention.

Setting.— Large tertiary care hospital.

Participants.— For the comparison of phase 1 and 2, all patients admitted to a stratified random sample of 6 medical and surgical units in a tertiary care hospital over a 6-month period, and for the randomized comparison during phase 2, all patients admitted to the same units and 2 randomly selected additional units over a subsequent 9-month period.

Interventions.— A physician computer order entry system (POE) for all units and a team-based intervention that included changing the role of pharmacists, implemented for half the units.

Main Outcome Measure.— Nonintercepted serious medication errors.

Results.— Comparing identical units between phases 1 and 2, nonintercepted serious medication errors decreased 55%, from 10.7 events per 1000 patient-days to 4.86 events per 1000 (P=.01). The decline occurred for all stages of the medication-use process. Preventable ADEs declined 17% from 4.69 to 3.88 (P=.37), while nonintercepted potential ADEs declined 84% from 5.99 to 0.98 per 1000 patient-days (P=.002). When POE-only was compared with the POE plus team intervention combined, the team intervention conferred no additonal benefit over POE.

Conclusions.— Physician computer order entry decreased the rate of nonintercepted serious medication errors by more than half, although this decrease was larger for potential ADEs than for errors that actually resulted in an ADE.

From the Division of General Medicine, Departments of Medicine (Drs Bates and Seger and Ms Vander Vliet), Emergency Medicine (Dr Teich), Quality Management (Drs Hickey and Kleefield), and Pharmacy (Dr Shea), Brigham and Women's Hospital; the Center for Applied Medical Information Systems Research, Partners Healthcare Systems and Harvard Medical School (Drs Bates and Teich); the Department of Anesthesiology, St Elizabeth's Medical Center (Dr Cullen); and the Department of Biostatistics (Dr Laird) and Health Policy and Management (Dr Leap and Ms Burdick), Harvard School of Public Health; and Health Services Research and Development, Brockton/West Roxbury Veterans Affairs Medical Center (Dr Petersen), Boston, Mass.

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