Deploying information technology and continuous control monitoring systems in hospitals to prevent medication errors.
The healthcare system is not as safe as it should and could be. The identification of possible risks related to hospital care is crucial to the healthcare system, due to their serious repercussions on patient health. Other factors, such as economic and legal aspects, as well as trust in the system, have also been affected by these risks. This interest in risks related to healthcare errors is not something new. Numerous studies have been carried out to quantify these errors. Schimmel (2003) noted that approximately 20% of patients admitted to a university hospital suffered some sort of iatrogenesis (1), a fifth of which had resulted in serious complications. Steel et al. (1981) raised this figure to 36%, one quarter of which were serious. In both studies, the main risk was due to medication errors. Many studies have taken place over time in different countries, with results quantifying healthcare errors in an approximate interval of between 4% and 20% (Baker et al. 2004; Brennan et al. 1991; Davis et al. 2001; Forster et al. 2004; Leape et al. 1991; Schioler et al. 2001; Thomas et al. 2000; Vincent Neale & Woloshynowych. 2001; Wilson et al. 1995).
Improvements in the healthcare system should be based upon the premise that 'to err is human' (Kohn Corrigan & Donaldson 2000). Regardless of an individual's ability or degree of concentration, it is human nature to commit errors. Therefore, systems designed to prevent errors might include procedures created to detect and avoid such mistakes through a systems approach, rather than focusing on the traditional 'people approach' (Reason 2000).
The systems approach is based on the idea that errors can be prevented by designing work systems in such a way that errors are difficult to make. This is the essence of this approach to error reduction: focus on the processes, not on the people (Leape 1999). However, it is not always easy to make changes to work systems. These changes normally involve process re-engineering, resulting in organisational changes that affect both the way work is done and how centralised information is controlled. Under these circumstances, personnel can reject alterations in the work system, as they are normally reluctant to change their work routines, and feel that closer supervision might be problematical (Anderson 1997; Plotnick 2010). Thus, employees can resist change due to fear of the unknown or simply due to the sensation of displacement that some members of the organisation will feel. Information technology (IT) can play a fundamental role within the scope of the systems approach. Prior research has shown that the benefits of IT and a number of empirical studies demonstrate the positive relationship between the investment in technology and operational improvements (Bender 1986; Dewan & Ren 2011; Harris & Katz 1991, Huang 2007).
The main objective of this paper is to examine the potential benefits that hospitals can obtain from implementing IT and continuous control monitoring (CCM) systems designed to support and facilitate internal control processes; that is, the adoption of IT as a form of change mechanism (Ward et al. 2000). A case study is presented to analyse how IT tools can be used for designing work systems so that medication errors are difficult to make, thereby increasing patient safety.
Medication errors and CCM systems
Medication mistakes are the leading type of healthcare errors affecting patients (Bates 2007; Leape et al. 1991). A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, healthcare products, procedures and systems, which include prescribing, order communication, product labeling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use (NCCMERP 2011). Medication errors may originate in one or more of four sequential stages in the drug ordering and delivery system as shown in Figure 1 (Leape at al. 1995).
[FIGURE 1 OMITTED]
Several people intervene during each stage of the drug ordering and delivery system, thereby increasing the potential risk at each stage. However, medication errors mainly take place during the physician ordering and administration stages (Bates et al. 1995; Leape, Bates & Cullen 1995) (Figure 2).
In order to improve patient safety, the most frequent causes of medication error should be identified. Thus, mechanisms can be designed to prevent them using a systems approach. Table 1 summarises the major errors made by proximal cause and stage of drug ordering and delivery (Institute for Safe Medication Practices 2000; Nadzam 1998).
CCM systems expand the scope of control processes. CCM systems encompass a range of control monitoring tasks, including the automation of routine control tests, enhanced risk assessments, evaluation and documentation of controls, and managing and communicating control assurance activities. The role of CCM systems is to ensure that internal control continues to operate effectively by promoting good control operations, and enhancing the process of assessing the design and operation of controls (Committee of Sponsoring Organizations of the Treadway Commission 2009). Monitoring tools generally evaluate one or more of the following, prompting an assessment about the underlying elements of the situation-specific context (Ramamoorti & Dupree 2010):
* Transaction data: highlighting exceptions through comparisons of processed transactions (or master data) against a set of pre-defined control rules.
* Conditions: comparing baseline or previously established expectations with actual applications or parameter configurations.
* Changes: identifying and reporting changes to critical resources, data or information allowing verification of authorisation and/or propriety.
* Ensuring information (processing) integrity: verifying and monitoring the accuracy, consistency and reliability of information across content, process, system and environment (i.e. information integrity).
* Error management: monitoring the volume and resolution of activity in suspense areas, error logs or exception reports and the management of the workflow of control exceptions.
CCM systems are involved in different parts of the information management system (Figure 3). Processes can automatically be controlled as they occur, with the necessary degree of unbundling. The objective is to prevent errors in generating digital information, sidestepping the GIGO effect (Garbage In, Garbage Out). Its analysis capability enables control of all transactions or actions taking place in the area of interest. Therefore, there are no risks associated with sample sets or confidence intervals. They can also integrate data collected from multiple processes, while sending alert messages when anomalies are detected.
[FIGURE 3 OMITTED]
The following steps comprise the continuous monitoring application: determine the scope of the monitoring and the methods and techniques to be applied; determine the controls, indicators, and rules to be used; design and document the system; record the findings and prepare management reports; and update the system to improve the predictive ability of the system (Nigrini & Johnson 2008). The use of IT systems based on the CCM philosophy could be an alternative for partially preventing the risks inherent to predominantly manual processes that currently take place in a great deal of hospitals.
Method: the case study
Contrary to other empirical research methods, case studies make it possible to analyse contemporary phenomena in their true context, when the demarcations between the two are not so clear, and when multiple evidence sources are used (Yin 1994). Case study methodology is recommended as a means of increasing the contact between research and the reality of the business world (Huq & Martin 2006; Stefanou & Revanoglou 2006) and is highly appropriate in the early stages of research of a phenomenon (Eisenhardt 1989). Further, the case study has been recommended as the ideal research methodology for gaining a better understanding of complex phenomena (Flynn et al. 1990; McCutcheon & Meredith 1993), and the design and implementation of new processes and control systems in hospitals is a complex task that cannot be fully understood on its own.
Healthcare institutions are complex, multifunctional, information-intensive organisations requiring sophisticated integrated management information systems (Stefanou & Revanoglu 2006), therefore making it possible to analyse the role of different users. Most medical organisations produce an abundance of medical documents that are used to support a variety of processes within these organisations (Ribeiro-Neto, Laender & Luciano 2001). The analysis of IT used in healthcare organisations is a very interesting field of research (Jamal, McKenzie & Clark 2009). For instance, Handel et al. (2011) present a research agenda addressing the major questions that are posed by the introduction of IT into emergency department care; these questions relate to interoperability, patient flow and integration into clinical work, real-time decision support, handoffs, safety-critical computing, and the interaction between IT and clinical workflows.
Due to the informational nature of this study, the selection of the hospital to be studied was not random, but specific in nature (Eisenhardt 1989). This longitudinal case study was carried out in the Infanta Elena Hospital (IEH), due to its public nature, including autonomous administration as well as economic management departments. IEH is a Spanish hospital created in 1985. It provides healthcare coverage to an estimated 200,000 individuals located in 17 different towns. Its installations include over 40 doctor's offices, nine operating theatres and 320 beds, with a full-time staff of 1,100 including physicians as well as healthcare and other employees. The IEH understands that information management is one cornerstone of system operation, and that the incorporation of IT is essential in order to handle the information adequately. This is true not only at the strategic and tactical levels for decision support, but also at the operating level, to facilitate daily clinical activity. Top management has shown an interest in seeking efficient solutions to prevent medication errors.
Traditionally, at the IEH the drug ordering and delivery process was handled manually, with no IT support. A review of the pharmacy service indicated that working procedures might be improved to prevent certain medication errors, and that it was important to include more widespread controls to detect these mistakes when they take place. With managers' support, in April of 2007 a project began deploying IT and CCM systems with two major focuses: (1) The modification of work process through the use of IT making it difficult to commit medication errors, and (2) the introduction of control mechanisms using CCM-oriented systems making it possible to detect and correct medication errors as they occur.
The project lasted four years beginning in 2007. These changes involved the process re-engineering, resulting in organisational changes that affected the way work is done. This study analyses the role of IT as catalysts of designing work systems. It also analyses the implementation of systems to detect and correct medication errors before harm occurs, with special attention paid to the new system's focus on risk reduction.
The 'old' system vs the 'new' system
This section presents the main characteristics of both systems and the results obtained by using the new system.
The 'old' drug ordering and delivery system
The main characteristic of the previous system is that the entire process took place without IT support. The process was entirely manual, and therefore, potential mistakes were hard to control (Figure 4).
[FIGURE 4 OMITTED]
At this stage, physicians wrote hand-written prescriptions. Thus, each day they wrote their prescriptions, including symbols and abbreviations, featuring the required dosage and administration form. These hand-written prescriptions were given to the nursing staff to continue the process. During this stage, doctors did not have computerised systems assisting them with detailed information regarding drugs and patients. All supporting documentation was on paper. Using information at his/her disposal, the physician had to manually verify the following: the lack of possible adverse drug interactions with chronic medication, the correct dosage, and that there were no allergies or other reasons making the prescriptions inadvisable based on the patient's history.
The nurses then received the written prescription on their unit, transcribing them onto a single form, requesting the quantity of medicine required from the pharmacy. The transcription of prescriptions did not add value to the drug ordering and delivery process, and was the source of many potential risks. It was clear that the elimination of handwritten prescriptions and the development of electronic prescribing would reduce these types of medication errors (Institute for Safe Medication Practices 2000). Grouping the entire unit's prescriptions in one pharmacy request form made it impossible to carry out external controls, and therefore the risk inherent in the process was greater.
After the nursing staff had sent the drug request form to the pharmacy, it dispensed the requested drugs to each hospital unit or service. The requests were not broken down according to patients, and therefore the pharmacy simply filled the prescriptions required without having knowledge regarding which drugs and dosages were to be administrated to each patient. These drugs were then distributed by hand to each unit, and stored in small cabinets on each unit, with nurses in charge of organising the drugs in them, as well as dispensing them without any pharmacy supervision.
Administration to the patient
Based on instructions in the doctors' prescriptions, the nursing staff administered the drugs to patients. Nurses collected drugs manually from the unit's stock and administered them to the patients based on the physicians' dosage instructions. This required a hand count so that each patient received exactly the drugs prescribed by his/her doctor. This meant having to make a daily recount of prescription medication, checking the result against the nursing administration sheet. Periodically, nurses requested that certain drugs be replaced so as to have safety stocks.
The 'new' drug ordering and delivery system
In April of 2007, a project aiming to prevent medication errors through the use of IT and CCM systems began. Among other innovations, the handwritten prescription and traditional units' cabinets were substituted by computerised physician order entry (CPOE) and automated unit-based medication storage and distribution systems, all employing integral procedures (Figure 5).
[FIGURE 5 OMITTED]
Medication is the most commonly used intervention in healthcare, yet despite its benefits, it leads to an estimated 1.5 million adverse drug events and tens of thousands of hospital admissions each year. Although some are not preventable given what is known today, many types are, one of which being drug-drug interactions (Classen, Phansalkar & Bates 2011).
The implementation of CPOE systems is an important shift in the way drugs are ordered and delivered. Under the new system, doctors do not write prescriptions by hand, instead using a CPOE system. To simplify this stage, e-prescription technology was installed in the hospital's intranet so that physicians can log in from any online computer. Instead of generating paper-based prescriptions, e-prescriptions are produced, making it possible to establish new CCM systems. Physicians have the necessary information to carry out the task digitally. They have online access to each patient's pharmacological and therapeutic case history, data on maximum dosage, interactions, and duration of treatment for each drug, and details regarding each patient's allergies and relevant personal situations.
Using the CPOE system, all doctors prescribe following the same procedure, thereby increasing the standardisation of prescriptions through the use of established protocols. Furthermore, CCM systems alert of potential situations of interactions and incompatibilities between prescribed drugs, interactions or incompatibility with ones taken previously, and interactions between prescribed drugs and the patient's history (e.g. allergies).
Once the physician has sent in the e-prescription, the information is digitally saved into the application so that the pharmacy can gain access to it. Therefore, it is unnecessary for nurses to manually transcribe the handwritten prescriptions, this process disappearing thanks to IT support. Nurses' roles have changed. A great deal of their time used to be devoted to bureaucratic tasks such as transcription, to the detriment of time spent on patient care. The nursing staff are thereby freed from activities that do not add value to their roles and which are also the source of potential risks, to focus on the key aspects of their jobs.
Traditional pharmaco-surveillance methods do not provide timely information on drug safety and effectiveness. Real-time surveillance using electronic prescribing systems could address this problem (Eguale et al. 2008). Unlike the old pharmacy service system, the new system provides pharmacists with access to e-prescriptions broken down by patients, rather than by hospital unit or service. This represents an important change in the role of pharmacists in the drug ordering and delivery system. Rather than simply dispensing medicine, they become part of a multi-disciplinary team specialised in drugs. Using each patient's e-prescriptions, pharmacists may carry out additional controls on each of the e-prescriptions. The pharmacist reviews each e-prescription to detect medication errors. If an error is detected, the pharmacist communicates it to the doctor through the same CPOE system.
The drug dispensing procedure has also been improved through the use of automated unit-based medication storage and distribution systems. Previously, the pharmacy supplied each unit with the requested medicine, which was then transferred to and administrated from the cabinets on each unit. Now nurses directly withdraw the prescribed medication for the patients using automated unit-based storage and distribution systems located in the hospital units, once the e-prescription has been validated by the pharmacy. Manual dispensing is eliminated and replaced by automated dispensing machines.
Administration to the patient
Nurses still administer drugs to patients. Automated dispensing machines have replaced the cabinets on each unit. Now, these are electronically-controlled cabinets connected through different applications. Their features include a keyboard and tactile screen, which are used for completing all functions: identifying the user (physician, pharmacist, or nurse), selecting the patient, withdrawing and replacing medication, etc. These automated dispensing machines are placed in clinical units and are connected to a central console, which is located within the pharmacy; all the peripheral units are managed through them.
The ID of all users who use the system is always recorded. Nurses identify themselves in the automated unit-based medication storage and distribution systems via fingerprint identification; this is another control that records which staff member has withdrawn and administrated which medication to which patient. Once identified, the employee selects the patient, and the machine dispenses the exact amount of drugs prescribed by the doctor on the e-prescription that has been previously validated by the pharmacy.
The medication error dilemma is at the forefront of most hospitals' improvement agendas. The most often cited solution to the problem has been CPOE systems and automated dispensing machines. These systems have significant potential to reduce errors associated with illegibility as well as inappropriate drug use and dosing (Sengstack & Gugerty 2004). Hospitals are moving from manual to digital systems based on assumptions about the value of IT and CCM systems: for example, that they will improve the efficiency of services or patient outcomes (Keen & Muris 1995, Levick & O'Brien 2003). Ammenwerth et al. (2008) analysed the relative risk reduction on medication error and adverse drug events by CPOE systems. Of the 25 studies that analysed the effects on the medication error rate, 23 showed a significant relative risk reduction of 13% to 99%. Six of the nine studies analysing the effects on potential adverse drug events showed a significant relative risk reduction of 35% to 98%. Four of the seven studies that analysed the effect on adverse drug events showed a significant relative risk reduction of 30% to 84%. However, further research might ascertain whether the actual implementation of computerised physician order entry systems are achieving goals such as improved patient safety (Metzger et al. 2010; Moniz et al. 2011).
This paper is focused in the implementation process and uses a case study to analyse the role of IT and CCM systems in hospitals to prevent medication errors. The strategic role of IT can be classified into three categories (Dehning, Richardson & Zmud 2003; Schein 1992; Zuboff 1988). IT can replace human labour in automating business processes. Furthermore, IT can provide information about business activities to senior management and/or provide information about business activities to employees across the firm. Last but not least, IT can also transform the organisation and redefine business processes and relationships. In the IEH case study, important results came to light from each of the stages. These are discussed based on the previous classification.
Automate: Replace human labor in automating business processes
CPOE systems used during the physician ordering automatically detect possible prescription errors, such as drug interactions or likely side effects considering the patient's history. The transition from paper-based to e-prescriptions allows nurses to focus on tasks unrelated to transcription and requesting drugs from the pharmacy, as this all takes place automatically. CPOE systems have led to advancements in the prevention of prescription and transcription errors, as they affect the proximal causes of this stage of drug ordering and delivery system (Table 1).
Automated unit-based medication storage and distribution systems make it possible to dispense drugs automatically according to e-prescriptions. Previously, there were numerous opportunities for error, since the nurses were expected to interpret and transcribe the prescriptions as well as prepare medication for patients, without any pharmacy intervention or supervision. Automated unit-based medication storage and distribution systems increase the efficiency of the drug dispensation and administration process, thereby preventing medication errors, while reducing the pharmacist's workload, and guaranteeing the immediate availability of medicine in the nursing units and controlling inventory. The system also alerts when the nursing staff has not withdrawn patient medication.
Inform: Provide information about business activities
IEH's main goal has been the improvement of safety and care provided to patients; also, great strides have been made in improving the information available to assist in managing the hospital. The first change, which was mentioned previously, was the online information on patients and drugs available to doctors. The pharmacy can consult patients' detailed e-prescriptions. This makes it possible to easily analyse drug costs, breaking them down by service, patient, and diagnosis-related groups (DRG), which was previously impossible.
Automated dispensing machines facilitate a greater degree of control on the drug inventory. The use of traditional cabinets on each unit increase the drug costs due to the high inventory of stocks required, increasing the risk of expiration and deterioration due to their incorrect conservation. In the new system, stock management shows notable improvement thanks to awareness of the exact stock in each dispenser, thereby reducing wasted inventory. The system also makes it possible to send messages and increase information flow. The integration involves the improved flow of information while reducing administrative costs (Gattiker & Goodhue 2000). This integration is important because the inability to share information across systems seriously affects the efficiency and cost-effectiveness of healthcare organisations (Grimson, Grimson & Hassalbring 2000). Furthermore, personnel's participation in management could be one of the critical factors affecting intangible hospital value (Lu, Tsai & Yen 2010).
Transform: Redefine business processes
CPOE systems and automated dispensing machines have restructured existing work procedures, affecting the workflow between different professional groups. The system results in the reassignment of tasks and reallocation of areas of expertise in the medication process (Niazkhani et al. 2010). Therefore, the new systems have been catalysts for process reengineering, with redefined tasks of personnel involved in the new drug ordering and delivery system (Figure 6).
[FIGURE 6 OMITTED]
[FIGURE 7 OMITTED]
Recognising that change does not take place easily or all at once, IEH chose not to implement the new system throughout the entire organisation simultaneously. It was gradually set up over a four-year period, following a 'phased rollout' implementation methodology (Markus et al. 2000). Implementation began in areas perceived as more receptive to change, and then extended to other hospital areas (Figure 7). To avoid problems, during the two weeks following implementation of the new system both systems remained active. Once these two weeks were up, only the new system remained operative.
Resistance to change was considered a main risk. However, this was minimised due to two factors making a decisive contribution to achieving the set goals: continual involvement of management and continuous training provided to those involved. It is even possible that the process might not have been implemented had the top management support been weak.
Top management formed an Implementation Committee to ensure a smooth implantation process. The team was comprised of the following members: the Project Manager, Functional Consultants, and Technical Consultants. The Hospital Administrator stepped in as Project Manager. Functional Consultants included the head of each clinical unit (physicians and nurses), as well as the pharmacy head. The Technical Consultant was an employee from the company hired to carry out the implementation. The Project Manager's role included analysing, defining, and designing the entire process. It also included directing the project, securing involvement of all the different groups, while at the same time overseeing the project with an eye to fulfilling deadlines. The Functional Consultants analysed processes in order to detect those that could be automated, while also defining authorisation policies for obtaining access to information. The Technical Consultants configured the technical infrastructure in order to set the system up, and also installed and configured software as specified by the Project Manager and Functional Consultants. This Committee was also in charge of supervising the overall implementation process in each unit. It also designed the training courses to be given to personnel. In May 2007, the company that had been hired to set the system up trained pharmacy personnel on how the CPOE system and automated dispensing machines work. Since that time, the pharmacy staff has given specific training program to doctors and nurses every time another unit is set up with the new system. It is a continuous training course. Once new employees are hired, they are trained on how the system works. The pharmacy communicates system updates (such as new medication protocols and security updates) to the personnel involved.
Training was not exclusively focused on using the system, but was also focused on the new system's advantages, most of which are related to the patient's increased safety profile. As it was implemented gradually, all areas were able to observe its effect in those areas testing it first. The result was a predisposition of personnel towards using IT and CCM systems, along with the well-known implications of the reengineering of processes. In order to convince personnel to adopt IT and CCM systems, top management emphasised the functional benefits of the technology (from reduced paperwork to decreased medication errors). In general, both physicians and nurses seemed positive about CPOE before and after the implementation of this system (van Doormaal et al. 2010). In contrast to other cases (Plotnick 2010), there were positive attitudes toward behaviour change, mainly due to the potential of these new technologies to prevent medication errors and reduce the risks associated with patient treatment.
Once the system was set up in all the units, it went into use. The Implementation Committee created a technical support service located in the pharmacy department. This technical support service is in charge of resolving irregularities that arise, as well as making backups, analysing glitches in the system. Whenever a user detects a problem in the system and is unable to solve it personally, this technical support service is contacted. Personnel trained by the company having installed the system can then proceed to solve any of the problems that might arise. If they are unable to provide a solution, the installing company is contacted in order to do so (it offers a 24-hour help line, 365 days a year).
Following are observations about the steps taken to set up the continuous monitoring application (Nigrini & Johnson 2008). As expressed throughout this paper, the monitoring scope was limited to medication errors inherent in the original drug ordering and delivery system. The main challenge was to establish controls, indicators, and rules that would be used to prevent potential errors. It was necessary to establish safety intervals for each drug and dosage, as well as to define possible interactions with other drugs. This was the first filter, as the system alerts doctors in situations in which prescribed drugs conflicted with any established rules. Checks are also made to see that there are no incompatibilities between the prescribed drugs and the patient's history. A great deal of time was devoted to the development of this phase, especially in the first units in which it took place. The system was not set up in a generalised fashion until the establishment of a list of rules and controls considered sufficiently consistent, with tests made on the pilot units. It is continually updated to improve its preventive ability. When errors surpassing system controls are detected, the causes are analysed to include new rules or modify those in existence.
Evidence supporting the recommendations made in the Institute of Medicine report (Kohn, Corrigan & Donaldson 2000) includes research on IT to improve the quality and safety of healthcare sector. Technologies, such as CPOE systems and automated dispensing machines, undoubtedly play key roles, and institutions should be thinking seriously about implementing a number of these (Bates 2007).
The aim of this paper has been to analyse the role of IT as catalysts of designing work routines so that medication errors are difficult to make, using the systems approach. The design and implementation of the CCM systems were also explained. This primary contribution to this literature is the strategic role that IT and CCM systems have played in hospitals, replacing human labor in automating business processes, providing information about business activities and, fundamentally, redefining business processes and relationships. The end result has been the implementation of a system preventing errors in the drug ordering and delivery system. The system has also provided the opportunity to improve information available. Implementation of the new system was not quite as problematic as expected. The low resistance to change was the result of management's firm and constant support of the project, as well as continuous personnel training. Another important issue was that the system was introduced progressively, thereby ensuring a smooth transition process.
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Tomas Escobar-Rodriguez PhD
University of Huelva
Plaza de la Merced
21002 Huelva SPAIN
Pedro Monge-Lozano PhD
University of Huelva
Plaza de la Merced
21002 Huelva SPAIN
Ma Mercedes Romero-Alonso PharmD
Hospital Pharmacy Specialist
Spanish Health Care System
Carretera Huelva-San Juan del Puerto, S/N
21007 Huelva SPAIN
Ma Antonia Bolivar-Raya PharmD
Hospital Pharmacy Specialist
Spanish Health Care System
Carretera Huelva-San Juan del Puerto, S/N
21007 Huelva SPAIN
(1) Iatrogenesis refers to the inadvertent adverse effects or complications caused by or resulting from medical treatment or advice.
Table 1: Medication errors by proximal causes and stages of drug ordering and delivery MEDICATION ERRORS PROXIMAL CAUSE Prescription errors - Lack of information on adverse effects of drugs - Lack of information on patient pathologies and medical history - Distractions Transcription errors - Illegible, incorrect, or ambiguous medical prescriptions - Drugs with similar names - Constant interruptions or distractions - Distractions Dispensing errors - Drugs with similar names - Drugs with similar packaging or labeling - Distractions Administration errors - Confusion in identifying patients - Problems in administration equipment - Distractions Figure 2: Errors by stages of drug ordering and delivery system Dispensing errors 4% Administration errors 34% Prescription errors 56% Transcription errors 6% Note: Table made from pie chart.