Wrong Medication Orders Common, Put Patients at Risk

Elizabeth Millard

February 10, 2020

Medical errors are happening more often in obstetrics than many realize, report investigators, who spotted "near misses" in medication orders in their retract-and-reorder study.

"In our field, we talk about maternal health and maternal morbidity, but we don't often think about medical error as a potential contributor to patient safety," said Dena Goffman, MD, chief of obstetrics and associate chief quality officer at the Sloane Hospital for Women at New York–Presbyterian Hospital and associate professor in obstetrics and gynecology at Columbia University Medical Center in New York City.

Goffman presented findings from a 12-month study of retract-and-reorder events at the Society for Maternal–Fetal Medicine 2020 Annual Pregnancy Meeting in Grapevine, Texas.

She and her team used an electronic query to identify orders placed and then cancelled by the same physician within 10 minutes.

Of the 1,058,429 orders placed in 2018 for 16,691 obstetric patients, there were 516 retract-and-reorder events, for a rate of 48.8 per 100,000 orders. Medication errors — particularly common with uterotonics, tocolytics, antibiotics, and antihypertensives — accounted for half of those events.

There are unique safety concerns when it comes to retract-and-reorder events in obstetrics, said Goffman. Patients are more homogeneous than would be found on a typical patient ward — all are women, all are of reproductive age, and all are pregnant — which creates more potential for error in order placement.

The consequences of an error can be serious. Delayed execution of an order for the appropriate patient can lead to harm, and an incorrect order can expose the wrong patient to inappropriate diagnostic tests, interventions, or medications.

Goffman and her team also looked at event rates by clinician type, order type, and timing.

Notably, the most common retract-and-reorder events involved medication, and mistakes were more than twice as common during night shifts as during day shifts.

Table. Retract-and-Reorder Events
Category of Event Rate per 100,000 Orders
Clinician type  
House staff 64.1
Attending 37.6
Advance practice provider 31.7
Order type  
Medication 77.9
Diagnostic imaging 4.6
Other 46.9
Day 31.6
Night 72.6

Best Practices

This research is a strong starting point from which to evaluate best practices in terms of patient orders in obstetrics, said Christine Proudfit, MD, a maternal–fetal medicine specialist at NYU Langone Health in New York City.

"The most important element of preventing wrong patient orders is to identify the patient in two ways" — such as name and date of birth or name and medical record number — "prior to administering any medication or performing a procedure," she told Medscape Medical News.

At NYU Langone, they employ a number of communication tools, including read-back and closed-loop communication, in which clinicians verify the desired order for a particular patient and then any specifics, such as dose and route of administration for medication, prior to giving it, she explained. Making sure each patient is "known" to all team members is another best practice, she added.

"It is standard that labor and delivery physicians and staff discuss all patients on the labor floor, as a team, several times a day to allow everyone to have knowledge of all patients for whom they may provide care, particularly in an emergency situation," said Proudfit.

Another best practice is to involve the patient as an active member of her care team. This can be achieved with strategies such as nursing hand-offs and rounding with all physicians and nurses so the patient is a participant in discussions about her care.

"We ensure that the patient understands all her recommended treatment. This also allows her an opportunity to clarify her history and current status, if needed," Proudfit said. And "if two patients on the floor have the same last name, the electronic medical record automatically flags those charts and creates a name alert to highlight the potential for confusion."

Important Step Forward

This research represents a forward-thinking step toward reducing medical errors, said Sherry Ross, MD, an obstetrician and gynecologist at Providence Saint John's Health Center in Santa Monica, California.

"It highlights the need to protect patients and also physicians," she told Medscape Medical News. "The nature of obstetrics is that decisions need to be made on a quicker basis than in many other specialties, because when there's a problem, it's often an emergency and it usually happens unexpectedly. That can lead to distraction during patient orders when you're trying to move quickly."

A combination of new training processes for medical students and advanced technology options could be helpful in the future, Ross added.

"What we want our colleagues to walk away with is an understanding that this issue exists, and it's a potential problem, wherever they practice," said Goffman. In terms of next steps, she and her fellow researchers will be looking at system strategies that can be put into place to minimize error, particularly with house staff, like residents on the night shift.

"It's important to look at having the balance in staffing and in processes," she said. "Order entry should not be a high-risk activity."

Society for Maternal–Fetal Medicine (SMFM) 2020 Annual Pregnancy Meeting: Abstract 46. Presented February 7, 2020.

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