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These intercepted errors were not administered to the patient because either the pharmacist intercepted the prescription before administration or the nurse recognised the error.
There was a demonstrated benefit on patient outcome scores with CPOE prescribing when the intercepted errors were combined with the non-intercepted errors.
The severity and potential consequences of intercepted errors were independently assessed by two physicians.
When intercepted and non-intercepted errors were combined, CPOE was associated with an improvement in the error outcome scoring compared to HWP; however, the three intercepted errors that could have caused permanent harm or death all occurred with CPOE.
In this study, intercepted errors (e.g. where an incorrect dose of a drug was prescribed but not administered) were separated from non-intercepted errors (where the patient received the drug).
bIf we include intercepted errors, there was a significant difference (p = 0.01) due to increased error rate with HWP.
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A potentially fatal intercepted error occurred when diamorphine was prescribed electronically using the pull down menus at a dose of 7 mg/kg instead of 7 mg, which could have lead to a 70 times overdose.
With respect to the non-intercepted errors, there was no significant difference between groups (p = 0.51; Table 3).
We compare the rates and types of MEs and the potential outcome of intercepted and non-intercepted errors.
The patient outcome scores are given in Tables 2 and 3. Most of the errors were minor in outcome, although two non-intercepted errors with CPOE led to an increased length of stay or increased monitoring.
It was reassuring to note that no patients suffered permanent harm or death as a result of any non-intercepted error.
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