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Saturday, July 20, 2019  

Computer weaknesses may compromise safetyPublished 9/6/2005

Many hospital pharmacy computer systems may not be doing an adequate job of detecting potentially unsafe medication orders. According to surveys conducted by the Institute for Safe Medication Practices (ISMP), these systems are not reliably detecting and correcting prescription errors or pharmacy order entry errors, and little improvement has occurred over the last six years.

In 2005, only 4 of the 182 computer systems tested were able to detect all the unsafe orders. Disturbingly, less than half were able to detect orders for medications that exceeded a safe maximum dose. Another flaw was that when unsafe orders were detected, an average of 9 in 10 systems allowed the user to override the serious warnings, in most cases by simply pressing a function key.

Most systems were able to provide reports of drug warning overrides and permitted staff to build alerts for serious error-prone situations. However, only half of the computer systems tested allowed the use of tall man letters to differentiate look-alike drug names, and just 9% allowed users to change the font and color to highlight look-alike drug name pairs.

Two new areas tested in 2005 also fared poorly. Just 1 in 5 computer systems were able to intercept the entry of a contraindicated drug based on the patient’s diagnosis or condition (pregnancy). And only 1 in 4 was able to detect a clinically significant drug/herbal interaction.

Compared to the survey results from 1999, pharmacy computer systems in 2005 performed even less reliably in many areas. On the plus side, some improvement was observed with detecting contraindicated drugs or doses based on lab results.

Failure to update technology may be one explanation for the general lack of improvement in pharmacy computer systems over the last six years. More than half (56%) of the 2005 survey participants were using a pharmacy system that was at least 5 years old, with no recent upgrades. In fact, 38% had been using the same system for 8 years or more without upgrades.

Drug information providers’ software and lack of timely installation of updates may provide another explanation for poor field test results. If a software vendor deems certain types of warnings unimportant, they may be omitted. Or if the content is not current or adequate, important alerts may not appear.

The field test for pharmacists and full survey results can be found at

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