AHRQ Case and Commentary: Order Entry Errors in Electronic Prescribing

February 24, 2012 | Strategic Insights for Ambulatory Care


Clinicians should confirm the deletion of medication orders entered in error while reviewing a patient's current medication list at the end of his or her visit, as well as provide a paper or electronic copy to the patient, according to a commentary from the February 2012 edition of the Agency for Healthcare Research and Quality’s (AHRQ) online case study review, WebM&M. In the spotlight case, a 63-year-old man with multiple medical conditions was prescribed alprazolam by his primary care physician to help manage his anxiety. While entering the man’s prescription into the clinic’s electronic prescribing system, the clinic nurse accidentally entered an additional medication, atenolol, which was intended for a different patient. She immediately realized the error and deleted it from the system; however, her attempt to delete the error did not prevent the order from going through to the pharmacy, and the man began to take both medications as instructed.

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