Table 2

Examples of errors identified at each step in the inpatient medication management process before and after the CPOE implementation

Medication management process step	Examples
Medication management process step	Pre-CPOE implementation	Post-CPOE implementation
1. Ordering	1. Lack of countersignature from the paediatric team for prescriptions from external consultants. 2. Therapeutic duplication.*	3. Wrong drug selected from the drop-down menu (eg, immediate vs extended-release propranolol), leading to a decrease in blood pressure and heart rate.† 4. Use of manuscript prescriptions instead of CPOE formularies for a patient requiring insulin, leading to hyperglycaemia.‡ 5. A nurse stopped a drug order without approval from the medical team. 6. Wrong drug ordered verbally.*
1. Ordering	7. Wrong patient order. 8. Wrong prescription weight.
2. Acknowledgement*, transmission and transcribing	9. Order not transmitted to the pharmacy department ((a) prescription already faxed and then modified; (b) prescription never transmitted), resulting in patients not receiving their treatment, or receiving their treatment at the wrong time.† 10. eMAR not updated with discontinuation of treatment. 11. Transcription error in the eMAR (wrong patient, wrong medication).	12. Transcription error in the eMAR (wrong route of administration; eg, ear drops vs eye drops) due to incorrect system configuration.
2. Acknowledgement*, transmission and transcribing	13. Confusion related to the use of automatic comments on orders (eg, all inhaler orders have a comment mentioning that the drug will be administered by a respiratory therapist, although not everyone was aware).*
3. Pharmacy validation and dispensing	14. Preparation error (wrong quantity).*	15. See common examples listed below.
3. Pharmacy validation and dispensing	16. Drug not prepared by the pharmacy department (closed).* 17. Drug missing from dispensing cabinet.*
4a. Nurse administering—preparation	18. See common examples listed below.	19. eMAR did not reflect the accurate medication list (not refreshed).* 20. Incorrect reading leading to the wrong dose of insulin (25 units vs 2.5 units), resulting in a rapid glycaemia decrease.*†
4a. Nurse administering—preparation	21. Wrong dose administered. 22. Wrong timing (too early or too late) (eg, not receiving Tylenol, leading to fever).‡ 23. Lack of compliance with controlled drug policies. 24. Lack of double checking for high-risk medications. 25. Drug administration not documented accordingly (the drug was administered but not documented, or the drug was not administered but documented as administered).†
4b. Nurse administering—bedside administration	26. See common example listed below.	27. Drug administered incorrectly (intravenous compatibility issues, wrong dilution).† 28. Drug administered to the wrong patient.
4b. Nurse administering—bedside administration	29. Drug at the patient’s bedside but not administered.
5. Patient monitoring	30. No monitoring (therapeutic adjustments).

*Examples that were reported during one of the two periods and are specific to the process studied. They might not be related to the use (or lack of) of the CPOE.
†Events of severity D (adverse event requiring additional verifications but not leading to patient consequences).
‡Events of severity E1 (adverse event leading to patient consequences).
CPOE, computerised provider order entry; eMAR, electronic medication administration record.