1168
• COMPUTER-ASSISTED PRESCRIPTIONS
The Effect of Computer-assisted Prescription Writing on
Emergency Department Prescription Errors
Kenneth E. Bizovi, MD, Brandon E. Beckley, BS, Michelle C. McDade, BS,
Annette L. Adams, MA, MPH, Robert A. Lowe, MD, MPH,
Andrew D. Zechnich, MD, MPH, Jerris R. Hedges, MD, MS
Abstract
Objective: To determine whether computer-assisted pre-
scription writing reduces the frequency of prescription
errors in the emergency department (ED). Methods: A
pre–post retrospective analysis was used to compare er-
rors between handwritten (HW) and computer-assisted
(CA) ED prescriptions. Prescriptions were reviewed for
pharmacist clarifications. A clarification was defined as
an error if missing information, incorrect information, in-
correct dose, non-formulary medication, or illegibility
was the reason for clarification. The HW and CA error
rates were compared using odds ratios (ORs) with 95%
confidence intervals (95% CIs). Results: During the pre-
intervention period, there were 7,036 patient visits with
2,326 HW ED prescriptions filled for 1,459 patients.
There were 91 clarifications, with a rate of 3.9%. There
were 54 HW errors, for an error rate of 2.3%. During the
Adverse drug events (ADEs) make up a substantial
proportion of medical errors and are a major cause
of iatrogenic injury.1–6 Many of these errors are pre-
ventable.3 The publication by the Institute of Med-
icine, ‘‘To Err Is Human: Building a Safer Health
System,’’ highlights the need for reduction of med-
ical errors. This report suggests that more than
From the Department of Emergency Medicine, Oregon Health
& Science University (KEB, ALA, RAL, ADZ, JRH), the School
of Medicine, Oregon Health & Science University (BEB, MCM),
the Department of Public Health and Preventative Medicine,
Oregon Health & Science University (ALA, RAL), and the Di-
vision of Medical Informatics & Outcomes Research, Oregon
Health & Science University (RAL), Portland, OR; the Leonard
Davis Institute for Medical Economics, University of Penn-
sylvania (RAL), Philadelphia, PA; and the Department of
Emergency Medicine, Providence St. Vincent’s Medical Center
(ADZ), Portland, OR.
Received March 1, 2002; revisions received June 19, 2002, and
July 23, 2002; accepted July 26, 2002.
Presented at the SAEM annual meeting, Atlanta, GA, May 2001,
and the SAEM Western Regional Forum, Newport Beach, CA,
March 2001.
The work of Brandon E. Beckley was supported by NIH grant
T 35 HL 07890.
Address for correspondence and reprints: Ken Bizovi, MD,
Oregon Health & Science University, CSB 550, Department of
Emergency Medicine, 3181 SW Sam Jackson Park Road, Port-
land, OR 97201. Fax: 503-494-0615; e-mail: bizovik@ohsu.edu.
Bizovi et al.
post-intervention period, there were 7,845 patient visits
with 1,594 CA prescriptions filled for 1,056 patients.
There were 13 clarifications, with a clarification rate of
0.8%, and 11 errors, for a CA error rate of 0.7%. The CA
prescriptions were substantially less likely to contain an
error [OR 0.31 (95% CI = 0.10 to 0.36)] or to require phar-
macist clarification [OR 0.19 (95% CI = 0.10 to 0.36)] than
were the HW prescriptions. Conclusions: Computer-as-
sisted prescriptions were more than three times less
likely to contain errors and five times less likely to re-
quire pharmacist clarification than handwritten prescrip-
tions. Key words: emergency medicine; prescription
drugs; medication errors, prevention and control; human
drug therapy; computer-assisted medication systems.
ACADEMIC EMERGENCY MEDICINE 2002; 9:1168–
1175.
40,000 Americans die each year as a result of med-
ical errors. This estimate has been challenged, but
preventable medical error remains an important is-
sue.7
Computer applications are one approach to re-
ducing medication errors. Although others have
addressed the use of computer-assisted (CA) drug
therapy, few published studies address prescription
writing.8,9 Additionally, only a small number of
emergency medicine studies address ADEs and
prescribing errors.10–13 Computer-assisted prescrip-
tion writing represents a new tool in the practice of
emergency medicine.
The emergency department (ED) at Oregon
Health & Science University (OHSU) recently im-
plemented a CA prescription writing system, which
provided the opportunity for a ‘‘natural experi-
ment,’’ studying the potential for reducing errors
using CA prescription writing. We anticipated that
the use of CA prescription writing would lead to a
reduction in the number of ED prescription errors
and potential ADEs when compared with hand-
written (HW) ED prescriptions, but at the time of
implementation this was uncertain. The purpose of
this study was to evaluate the impact of CA pre-
scription writing on ED prescription error rates.
ACAD EMERG MED • November 2002, Vol. 9, No. 11 • www.aemj.org
METHODS
Study Design. This was a retrospective pre–post
study of the error rate between HW and CA pre-
scriptions for ED patients.
The study was reviewed by the OHSU institu-
tional review board (IRB), which judged it to be
exempt from further IRB review under 45 CFR
46.101, Category 4. The IRB waived the require-
ment for informed consent for this study.
Study Setting and Population. The OHSU ED is
based in a tertiary care, teaching hospital and sees
approximately 45,000 patient visits per year. This
ED is the primary site for an emergency medicine
residency and the hospital is the primary site for
the OHSU medical school. Care providers in the ED
include off-service residents, emergency medicine
residents, nurse practitioners, and emergency med-
icine faculty physicians. Medical students are su-
pervised by senior emergency medicine residents
and faculty and do not write prescriptions.
The OHSU ED has been using a centralized in-
formation system (EmSTAT, CyberPlus Corpora-
tion, Austin, TX) since 1997. The EmSTAT system
consists of several modules, including patient
tracking, discharge instructions, and communica-
tions functions, and serves as the backbone of in-
formation systems in the clinical operation of the
ED as well as a rich clinical database for research
and quality assurance activities.
On March 7, 2000, a CA prescription writing
module was implemented. This program allows the
prescriber to choose from a computer prescription
pick-list. The necessary information for each pre-
scription, such as medication dose, quantity, fre-
quency, and amount to dispense, is contained in
each prescription. The program integrates patient
name, medical record number, account number,
date of birth, age, sex, and prescriber name with
the medication prescription. Additionally, the pa-
tient’s weight is incorporated into the prescription
TABLE 1. Error Types Addressed by Computer-assisted Prescription Writing and Pharmacist Clarifications
Computer-assisted Prescription
Medication Error Expected to Impact
Missing information Yes
Incorrect information Yes
Incorrect dose Yes
Illegible Yes
Transcription error Yes
Non-formulary Yes
Medication not indicated No
Medication contraindicated No
Allergy No
Medication selection No
*Incorrect frequency and incorrect route are potential adverse drug events.
1169
for patients who weigh less than 50 kg. Previous to
implementing this system, the prescriber would use
a prescription pad, stamp the patient information,
and hand-write the prescription.
In the CA system there are some fill-in prescrip-
tions. Two types of fill-in prescriptions exist, pedi-
atric fill-in prescriptions and fill-in prescriptions
that allow the prescriber to create prescriptions not
included on the CA prescription list. These pre-
scriptions contain the medication, formulation, and
sometimes the dosing interval. The prescriber must
fill in the remainder of the prescription. Pediatric
fill-in prescriptions are necessary in this system in
order to adjust dosages for patient weight.
Computer-assisted prescription writing was ex-
pected to decrease errors related to incorrect dos-
ing, missing information, incorrect information,
legibility, ordering of non-formulary drugs, and
transcription (Table 1). These error types are likely
to result in a prescription that cannot be filled with-
out the pharmacist’s obtaining clarification from
the prescriber.
Pharmacist clarification was used as a marker for
the impact of the CA prescription writing. Table 1
illustrates how clarifications correspond to those er-
rors affected by CA prescription writing. Each error
that CA prescription writing is likely to impact
should be addressed by pharmacist clarification,
with the single exception of transcription errors.
Transcription errors refer to the pharmacist’s look-
ing at the prescription, transcribing a different drug
onto the label, and subsequently filling the bottle
with the medication on the label.
Inclusion Criteria. Handwritten prescriptions from
May 1, 1999, to June 30, 1999, (pre-intervention pe-
riod) and CA prescriptions from May 1, 2000, to
June 30, 2000, (post-intervention period) filled by
the OHSU pharmacy were identified as ED pre-
scriptions. The May 1, 2000, date was chosen to al-
low two months for the ED prescribers to become
Pharmacist Clarification Potential Adverse
Expected to Discover Drug Event
Yes No
Yes *Some
Yes Yes
Yes No
No Yes
Yes No
No Yes
No Yes
No Yes
No Yes
1170
familiar with the CA prescribing module. The two-
month study period during each year was chosen
to ensure an adequate number of prescriptions in
each group based on a 20% reduction in error rate,
with an alpha = 0.05 and a beta = 0.20.
Exclusion Criteria. Prescriptions not filled by the
OHSU pharmacy were excluded. Because the pur-
pose of the study was to compare HW prescriptions
with CA prescriptions, HW prescriptions written
during the post-intervention period were excluded
from the primary analysis. However, because of the
possibility that such an approach might bias the
study in favor of the intervention, a sensitivity anal-
ysis was conducted based on an ‘‘intention-to-
treat’’ approach, as described in the Data Analysis
section below.
Key Variables
Outcome variable. Using the ED database, pre-
scriptions from the OHSU pharmacy were identi-
fied as ED prescriptions. ED prescriptions were re-
viewed for pharmacist clarifications. When a
pharmacist requires clarification on a prescription,
he or she documents the clarification on the pre-
scription and initials the changes. Both HW and CA
prescriptions are processed in the same manner.
The paper prescription is filled and stored by the
pharmacy. Clarifications are documented on the pa-
per prescription and stored along with those pre-
scriptions that do not require clarification. The in-
vestigators’ review of these stored paper records
identified clarifications for both HW and CA pre-
scriptions.
Clarifications were considered errors if they were
related to missing information, incorrect informa-
tion, incorrect dose, legibility, or non-formulary
medication. Missing-information errors were de-
fined as clarifications where the medication, dose,
or frequency was not included in the prescription.
Missing information on the quantity was not con-
sidered an error unless the frequency was ‘‘prn.’’
Incorrect-information errors were defined as clari-
fications related to drug names, formulations, or
doses that do not exist, or incorrect frequency or
route for the drug written. Clarifications were de-
fined as incorrect dose errors if the medication was
dosed too high for any patient, too high for the
particular patient, or too low for the patient. The
incorrect-dose errors based on too high or too low
for the patient were based on the pharmacist’s doc-
umentation on the prescription. Legibility errors
were clarifications due to illegible prescriptions.
Non-formulary errors were clarifications that were
due to medication that was not on the OHSU phar-
Bizovi et al. • COMPUTER-ASSISTED PRESCRIPTIONS
macy formulary. Of the errors affected by CA pre-
scription writing, incorrect-dose, and incorrect-in-
formation errors related to frequency or route,
represent potential ADEs (Table 1).
Clarifications not related to prescription error
were excluded from the calculation of error rates.
Handwritten errors were excluded as errors if they
involved medications not included on the com-
puter prescription list. Non-formulary errors were
excluded from the calculation of the overall error
rate but are reported separately.
Predictor variable. The predictor variable was
whether the prescription was handwritten or com-
puter-assisted.
Confounding variables. Analyses were adjusted for
patient age. We defined two age groups, pediatric
and adult. Pediatric patients were defined as pa-
tients less than age 14 years. We chose this age cut-
off because it corresponds with a typical weight of
50 kg or less, and patients weighing less than 50 kg
are likely to receive weight-based prescription
dosing.
In addition, adjustment was made for the iden-
tities of the ED provider caring for the patient. The
prescriber type was noted as faculty physician,
emergency medicine resident postgraduate year
(PGY) 3, emergency medicine resident PGY 2,
emergency medicine resident PGY 1, off-service res-
ident, or nurse practitioner.
Data Analysis. The statistical analysis of the clari-
fications, overall error rate, missing information, in-
correct information, incorrect dose, and potential
ADEs was designed to determine whether there
was an association between period (pre-interven-
tion vs. post-intervention) and the probability of
one or more prescription errors. Thus, the unit of
analysis was the patient visit. The analysis had to
take into account ‘‘clustering.’’ In other words, a
limited number of providers treated the patients in
this study, and a given provider might be more
likely to make errors on one patient if he or she
had made errors on other patients, violating the as-
sumption of statistical independence that is the ba-
sis for conventional statistical modeling. In order to
take clustering into account, we used a generalized
estimating equation (GEE) model to adjust for the
dependency of the repeated observations within
prescriber.14 The analyses of incorrect dose and po-
tential ADEs were not adjusted for individual pre-
scriber because no prescriber was represented more
than once among these events. All analyses were
adjusted for prescriber type (resident, nurse prac-
titioner, or faculty physician), patient age group,
ACAD EMERG MED • November 2002, Vol. 9, No. 11 • www.aemj.org
and number of prescriptions as possible confound-
ers. Data were missing in four HW prescriptions
where the prescriber could not be identified. None
of these four prescriptions had a clarification and
they were eliminated from the analysis. Odds ratios
(ORs) and 95% confidence intervals (95% CIs) were
calculated using the pre-intervention period as the
referent. Analyses were conducted using SAS ver-
sion 8.1 (SAS Institute, Cary, NC, 2000).
Because of the possibility that the intervention
would be less effective in patients aged <14 years,
who often received fill-in prescriptions in which
providers specified a weight-appropriate medica-
tion dosage, we also tested for a difference in the
effectiveness of the intervention in children com-
pared with adults. This was done using the Bres-
low-Day test for homogeneity, comparing the effect
of the intervention on age <14 years with the effect
on age ⱖ14.
A sample of HW prescriptions written during the
post-intervention phase was used to perform a sen-
sitivity analysis that evaluated the potential impact
of these prescriptions. The sample included the first
15 days of the post-intervention period. These data
were extrapolated to the entire post-intervention
period. Then crude ORs were calculated to describe
the potential impact of these prescriptions and were
compared with the results of the primary analysis.
Figure 1. Tree diagram of handwritten (HW) and computer-assisted (CA) prescriptions. OHSU = Oregon Health & Science University.
Figure 2. Rate of clarifications and errors for handwritten and computer-assisted prescriptions.
1171
RESULTS
During the pre-intervention period, there were
7,036 patient visits to the OHSU ED. The OHSU
pharmacy filled 2,326 HW ED prescriptions for
1,459 patients. Figure 1 shows a tree diagram of
clarifications, errors, and exclusions. There were 91
clarifications, with a clarification rate of 3.9%. There
were 37 HW clarifications that were not defined as
errors: unrelated to prescription error (4), not on the
CA prescription list (12), and non-formulary (21).
There were 54 HW errors, for an error rate of 2.3%.
Of these errors, three represented potential ADEs,
for a rate of 0.1%. For patients less than 14 years
old, there were 244 prescriptions written with 27
(11.1%) clarifications and 20 (8.2%) errors.
During the post-intervention period, there were
7,845 patient visits to the OHSU ED, and 2,169 CA
prescriptions were written. The OHSU pharmacy
filled 1,594 (73%) of the CA prescriptions for 1,056
patients. There were 13 clarifications, with a clari-
fication rate of 0.8%. Two CA clarifications were not
defined as errors. Both were unrelated to prescrip-
tion error. There were 11 errors, for a CA error rate
of 0.7%. Of these errors, two represented potential
ADEs, for a rate of 0.1%. For patients less than 14
years old, there were 84 prescriptions written with
two (2.4%) clarifications and two (2.4%) errors. Fig-
ure 2 compares HW and CA clarifications.
1172 Bizovi et al. • COMPUTER-ASSISTED PRESCRIPTIONS

The CA prescriptions were substantially less this difference in odds ratios for overall errors was
likely to contain an error, with an OR of 0.31 (95% not significant (p = 0.74).
CI = 0.16 to 0.59), or to require pharmacist clarifi- Although the CA system reduced errors, there
cation [OR 0.19 (95% CI = 0.10 to 0.36)] than were were still some errors in CA prescriptions. Fill-in
HW prescriptions (results based on GEE model ad- prescriptions accounted for five of the 11 CA errors.
justing for differences in prescriber type, number of Two of the CA prescription errors were related to
prescriptions written per visit, patient age, and errors on the computerized prescription pick-list.
clustering by individual prescriber). The error rates The pick-list contained one prescription with a
for each error type fell from the pre-intervention wrong route and another with a drug concentration
period to the post-intervention period, although the that does not exist. One other CA error was due to
confidence intervals for the odds ratios comparing an incorrect route. This prescription was complete
pre- and post-intervention error rates excluded 1.0 and appropriate for an oral antiemetic, but the
for the overall error rate and for incorrect infor- route was changed to rectal. Two of the 11 CA er-
mation on the prescriptions (Table 2). Error rates by rors were due to incorrect information related to
prescriber type for both HW and CA prescriptions duration of therapy.
are reported in Table 3. There were 70 CA fill-in prescriptions written, ac-
In testing for whether there was a difference in counting for 4.4% of the CA prescriptions. Fill-in
the effectiveness of the intervention for patients less prescriptions had a high rate of error (7.1%) and
than 14 years old versus patients 14 years old or accounted for five of the 11 CA errors (45%).
more, the unadjusted odds ratio for age <14 years Among the five errors related to fill-in prescrip-
was 0.27 (95% CI = 0.62 to 1.20) and the unadjusted tions, one was due to a formulation that does not
odds ratio for age ⱖ14 years was 0.36 (95% CI = exist (incorrect information), and the four others
0.17 to 0.76). A test for homogeneity revealed that had none of the fill-in fields completed. One of the
five fill-in errors was for a pediatric patient.
The sensitivity analysis using an ‘‘intention-to-
TABLE 2. Error Rates for Each Error Type* treat’’ principle confirmed the primary data analy-
Error Rate Error Rate Odds Ratio sis. During the first 15 days of the CA period, 380
Error Type HW CA (95% CI) handwritten prescriptions were filled at the OHSU
Overall errors† 2.32% (54) 0.69% (11) 0.31 (0.16, 0.59) pharmacy. There were ten clarifications, with a clar-
Missing infor- ification rate of 2.6%. There were six HW errors, for
mation 0.69% (16) 0.25% (4) 0.28 (0.07, 1.10) an error rate of 1.6%. Extrapolating these data to
Incorrect in-
formation 1.42% (33) 0.38% (6) 0.29 (0.13, 0.63) the entire CA period would give an adjusted clar-
Incorrect ification rate of 1.7% [OR 0.43 (95% CI = 0.31 to
dose 0.13% (3) 0.06% (1) 0.31 (0.06, 6.02) 0.60)], compared with the OR 0.19 (95% CI = 0.10
Illegible 0.09% (2) 0% (0) N/A to 0.36) in the primary analysis, and an adjusted
Non-formulary 0.90% (21) 0% (0) N/A
Potential ad-
error rate of 1.1% [OR 0.48 (95% CI = 0.31 to 0.73)],
verse drug compared with the OR 0.31 (95% CI = 0.16 to 0.59)
event 0.13% (3) 0.13% (2) 0.87 (0.14, 5.39) in the primary analysis. Thus, the sensitivity anal-
*HW = handwritten; CA = computer-assisted.
ysis still shows a clinically important reduction in
†Overall errors includes the sum of missing information, incor- errors with the implementation of the CA prescrip-
rect information, incorrect dose, and illegible errors. tion system.

TABLE 3. Error Rates by Prescriber Type*

Handwritten Computer-assisted
Prescriber Type No. Prescriptions No. Errors Error Rate (%) No. Prescriptions No. Errors Error Rate (%)
Faculty 784 17 2.17 320 2 0.63
PGY3 ED 343 5 1.46 527 3 0.57
PGY2 ED 303 10 3.30 275 1 0.36
PGY1 ED 84 1 1.19 70 1 1.43
Off-service 550 16 2.91 242 1 0.41
Nurse practitioner 258 5 1.94 160 3 1.88
Prescriber missing 4 0 0.00 0 0 N/A

Total 2,326 54 2.32 1,594 11 0.69

*PGY = postgraduate year; ED = emergency department. Analysis using Fischer’s exact test failed to demonstrate any difference
in error rate between prescriber types.
ACAD EMERG MED • November 2002, Vol. 9, No. 11 • www.aemj.org
DISCUSSION
The use of computers in other aspects of clinical
medicine has demonstrated the potential to de-
crease adverse events, change physician behavior,
preserve financial and medical resources, and im-
prove patient management.15–18 The implementa-
tion, careful study, and ongoing design of computer
interventions in medicine are critical to this effort.
In this study we have demonstrated that a CA pre-
scription writing module can decrease some pre-
scription writing errors, and reduce the need for
pharmacist clarification of prescriptions.
Schiff and Rucker identified several potential ad-
vantages of CA drug therapy, including increased
efficiency for physicians and pharmacists, timesav-
ing for patients, decreased transcription errors, im-
provement in formulary compliance, reduction in
medication errors, and improvement in quality of
medical care.19 Computer-assisted drug ordering
has been studied in the context of inpatient order
entry and has been shown to reduce the number of
ADEs and potential ADEs for hospitalized pa-
tients.18 Despite these demonstrated benefits,
few studies address outpatient prescription writ-
ing.8,9,18–20
Studies of ADEs point out that analysis of the
process of ordering and dispensing medications
can identify the steps where errors occur. Investi-
gators have suggested two primary safety objec-
tives: 1) to make it difficult for individuals to err,
and 2) to ‘‘absorb’’ errors that do occur, by detect-
ing and correcting them before harm occurs.21 In
theory, computerized systems can serve both of
these functions. The CA prescription writing mod-
ule described in this study addresses the first ob-
jective, making it more difficult for the prescriber
to err, by reducing or eliminating errors related to
missing information, incorrect information, incor-
rect dose, legibility, and formulary compliance.
When implementing a computer system, the cost
must be considered as well as the impact. The type
and composition of an ED’s baseline computer in-
frastructure can have a substantial impact on these
costs. Generally an ED computer system is imple-
mented with multiple goals in mind. We imple-
mented the CA prescription writing module as an
addition to an existing computerized patient track-
ing system. Training in the use of the CA prescrip-
tion writing included the production of a two-page
handout that showed the steps needed to write CA
prescriptions. The steps were similar to those re-
quired to complete other tasks in the system and
were readily learned by ED providers.
The costs for adding CA prescription writing to
our existing ED informatics system were small, and
1173
the anticipated benefits in addition to error reduc-
tion were substantial, including improved legibility,
readily accessible computerized records of prescrip-
tions for individual patients, and improved docu-
mentation of prescription writing by ED providers.
In our environment, a minimal reduction in error
rates would have been sufficient to justify contin-
ued use of the system. In selecting a sample size
for this study, we believed that a 20% reduction in
errors (RR ⱕ 0.8) would be sufficient to be clinically
important. However, physicians considering imple-
menting such a system in their EDs will need to
consider the trade-off of resource costs versus an-
ticipated benefits in their environments, where the
costs to add a CA prescription writing system may
differ. Therefore, the thresholds for error reduction
that may be sufficient to justify CA prescription sys-
tems may differ at different institutions. Neverthe-
less, the reduction that we observed—a relative
risk (RR) of overall errors of 0.3 when comparing
CA prescriptions with HW prescriptions—may be
sufficient to justify such a system in many settings.
This system impacts some but not all types of
prescription errors. Additionally, the system may
improve communication with the pharmacist and
formulary compliance. The prescription software
studied does not address errors related to medica-
tion indications, contraindications, selection, or al-
lergies (Table 1).
Despite the limitations of the CA prescription
writing intervention described, this study demon-
strates an impact on prescription error that should
be considered when designing and implementing
any CA prescription writing intervention. Both so-
phisticated systems and other simple CA prescrip-
tion writing systems should be evaluated for the
impact on errors related to missing information, in-
correct information, incorrect dose, legibility, and
formulary compliance.
The limitations of the current system define the
next step in improving CA prescription writing.
The use of computer applications in medicine is
still new but expanding rapidly. Evidence that a CA
prescription writing program decreases errors
should encourage the development and implemen-
tation of these systems. Incorporating allergies and
drug–drug interactions has been done with order
entry.18 Other aspects of medication selection such
as drug–patient and drug–diagnosis interactions
will require robust patient information databases.
Finally, medication selection based on the diagnosis
and the best choice of therapy would require that
the prescriber have point-of-care access to this in-
formation. Already steps are being taken to im-
prove our system, such as including patient aller-
gies in the prescription. Incremental improvements
1174
coupled with ongoing evaluation of errors, work-
flow, costs, and clinician satisfaction will assist in
further defining the impact of this and other CA
systems.
LIMITATIONS
The study was a retrospective study and had a
pre–post design. Therefore, it cannot control for
confounding and possible biases with the same
rigor as a randomized controlled trial.
One potential bias is that only those prescriptions
filled by the OHSU pharmacy were included in the
study. Of CA prescriptions, 73% were filled by the
OHSU pharmacy. Data on the fraction of HW pre-
scriptions filled at the OHSU pharmacy are not
available. The inability to track errors for prescrip-
tions filled outside of the hospital pharmacy raises
the possibility of bias due to incomplete follow-up.
However, for such a bias to affect the validity of the
study, not only would there have to be a difference
in error rates for prescriptions filled at the hospital
pharmacy compared with ‘‘outside’’ pharmacies,
but the amounts of change in the error rate from
the pre-intervention to the post-intervention period
would have to differ between the OHSU and out-
side pharmacies. Such a phenomenon seems ex-
tremely unlikely. Both CA and HW prescriptions
were handled in the same manner once the pre-
scription was completed. Both were given to the
patient at the time of discharge. The patient chose
the pharmacy where the prescription was filled.
The OHSU pharmacy documented clarifications
and stored these prescriptions in the same manner.
Clarifications were identified and defined as errors
in the same manner regardless of prescription type.
It is most likely that CA clarifications are easier to
identify since a pharmacist’s clarifications are
handwritten. This handwriting would be easier to
notice on a CA prescription where all the other text
except for the signature is printed.
It is possible that confounders affected the error
rates between the pre-intervention and post-inter-
vention periods. Some potential confounders were
accounted for in our statistical model, specifically
prescriber type, patient age, and number of pre-
scriptions. Additional potential confounders for
which we could not adjust include increased ED
provider awareness of medical error and training
that occurred during the implementation. It is pos-
sible that ED providers became more cognizant of
error during the time between the pre- and post-
intervention phases of this study. The training
handout that was circulated two months before the
intervention did have reminders to complete fill-in
prescriptions. However, previous studies of train-
Bizovi et al. • COMPUTER-ASSISTED PRESCRIPTIONS
ing alone (without CA interventions) have not
shown successful reduction in error rates, making
this explanation unlikely.22–24 The Hawthorne effect
seems less likely since the ED providers were not
aware that a study on prescription writing errors
was occurring.
The presence of fill-in prescriptions is due to the
pick-list of prescription options in the computer-
ized system. When writing prescriptions for pedi-
atric patients, the software cannot calculate a
weight-based dose. Therefore, the prescriber must
fill it in. Other fill-in prescriptions allow the pre-
scriber to choose a duration of therapy that is not
included on the prescription list. Fill-in prescrip-
tions account for a small fraction of CA prescrip-
tions (4.4%) but have a high frequency of error
(7.1%). Fill-in prescriptions require the provider to
enter information on the prescription in addition to
his or her signature. It appears that occasionally
when a fill-in prescription is printed, the provider
signs it and forgets to complete the prescription.
CONCLUSIONS
Computer-assisted prescriptions were more than
three times less likely to contain errors and five
times less likely to require pharmacist clarification
than were HW prescriptions. The positive results
from this limited intervention suggest the value of
further research with computerized tools that ad-
dress other aspects of medication safety in the ED.
References
1. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse
drug events and potential adverse drug events: implica-
tions for prevention. JAMA. 1995; 274:29–34.
2. Brennan TA, Leape LL, Laird NM, et al. Incidence of ad-
verse events and negligence in hospitalized patients. Re-
sults of the Harvard Medical Practice Study I. N Engl J
Med. 1991; 324:370–6.
3. Leape LL, Lawthers AG, Brennan TA, Johnson WG. Pre-
venting medical injury. Qual Rev Bull. 1993; 19:144–9.
4. Leape LL, Brennan TA, Laird N, et al. The nature of ad-
verse events in hospitalized patients; results from the
Harvard Medical Practice Study II. N Engl J Med. 1991;
324:377–84.
5. Faich G. National adverse drug reaction reporting, 1984–
1989. N Engl J Med. 1991; 314:1589–92.
6. Ogilvie RI, Ruedy J. Adverse drug reactions during hos-
pitalization. Can Med Assoc J. 1988; 97:1450–7.
7. Hayward RA, Hofer TP. Estimating hospital deaths due
to medical errors; preventability is in the eye of the re-
viewer. JAMA. 2001; 286:415–20.
8. Grams RR, Zhang D, Yue B. A primary care application
of an integrated computer-based pharmacy system. J
Med Syst. 1996; 20:413–22.
9. Walton RT, Gierl C, Yudkin P, Mistry H, Vessey MP, Fox
J. Evaluation of computer support for prescribing
(CAPSULE) using simulated cases. BMJ. 1997; 315:791–5.
10. Green SM, Clem KJ, Rothrock SG. Ketamine safety pro-
ACAD EMERG MED • November 2002, Vol. 9, No. 11 • www.aemj.org
file in the developing world: survey of practitioners.
Acad Emerg Med. 1996; 3:598–604.
11. Green SM, Clark R, Hostetler MA, Cohen M, Carlson D,
Rothrock SG. Inadvertent ketamine overdose in children:
clinical manifestations and outcome. Ann Emerg Med.
1999; 34:492–7.
12. Chin MH, Wang LC, Ma LJ, et al. Appropriateness of
medication selection for older persons in an urban aca-
demic emergency department. Acad Emerg Med. 1999; 6:
1232–42.
13. Wright SW, Wrenn KD. Appropriateness of vancomycin
use in the emergency department. Ann Emerg Med.
1998; 32:531–6.
14. Hu F, Goldberg J, Hedeker D, Flay B, Pentz M. Compari-
son of population-averaged and subject-specific ap-
proaches for analyzing repeated binary outcomes. Am J
Epidemiol. 1998; 47:694–703.
15. Schriger DL, Baraff LJ, Buller K, et al. Implementation of
clinical guidelines via a computer charting system: effect
on the care of febrile children less than 3 years of age. J
Am Med Inform Assoc. 2000; 7:186–95.
16. Tierney WM, Miller ME, McDonald C. The effect on test
ordering of informing physicians of the charges for out-
patient diagnostic tests. N Engl J Med. 1990; 322:1499–
505.
17. Tierney WM, Miller ME, Overhage M, McDonald C. Phy-
1175
sician inpatient order writing on microcomputer work-
stations: effects on resource utilization. JAMA. 1993; 269:
379–83.
18. Bates DW, Leape LL, Cullen DJ, et al. Effect of computer-
ized physician order entry and a team intervention on
prevention of serious medication errors. JAMA. 1998;
280:1311–6.
19. Schiff G, Rucker TD. Computerized prescribing: building
the electronic infrastructure for better medication usage.
JAMA. 1998; 279:1024–9.
20. Murray MD, Loos B, Tu W, Eckert GJ, Zhou XH, Tierney
WM. Effects of computer based prescribing on pharma-
cist work patterns. J Am Med Inform Assoc. 1998; 5:585–
6.
21. Leape LL, Bates DW, Cullen DJ, et al. Systems analysis
of adverse drug events. JAMA. 1995; 274:35–43.
22. O’Connor P, Amundson G, Christianson J. Performance
failure of an evidence-based upper respiratory infection
clinical guideline. J Fam Pract. 1999; 48:690–7.
23. Poses R, Cebul R, Wigton R. You can lead a horse to wa-
ter—improving physicians’ knowledge of probabilities
may not affect their decisions. Med Decis Making. 1995;
15:65–75.
24. Mainous A, Hueston W, Love M, Evans M, Finger R. An
evaluation of statewide strategies to reduce antibiotic
overuse. Fam Med. 2000; 32:22–9.