# A Case-Study of Metoclopramide Prescription Error : A Grim Reminder

## TL;DR

A hospital's CPOE system failed to update a medication library, leading to prescription errors for Metoclopramide, highlighting the need for pharmacist involvement and proactive medication management.

## Contribution

This case study highlights how outdated CPOE systems can lead to prescription errors and advocates for pharmacist integration in ICU teams.

## Key findings

- 2.98 errors per 1000 prescriptions involved 100 mg or more Metoclopramide dosages.
- 47.1% of errors occurred during on-call shifts with higher nurse workload.
- 68% of prescription errors led to actual administration of the medication.

## Abstract

The integration of Computerized Provider Order Entry (CPOE) systems in hospitals has been instrumental in reducing medication errors and enhancing patient safety. This study examines the implications of a software oversight in a CPOE system : Metoclopramide had a concentrated formulation (100 mg) delisted (and then not manufactured) in 2014 due to safety concerns. Despite this, the CPOE system continued to accept prescriptions for this formulation because it was not removed from the medication library by the pharmacist. The objective of our study was to describe this specific prescription error related to an outdated the medication library of the CPOE. We analyzed all metoclopramide prescriptions from 2014, to 2023. Our findings showed that errors involving 100 mg or more dosages were relatively rare, at 2.98 per 1000 prescriptions (34 errors in 11,372 prescriptions). Notably, 47.1% of these errors occurred during on-call shifts, and 68% of these errors led to actual administration. These errors correlated with periods of higher nurse workload. The findings advocate for the integration of dedicated pharmacists into ICU teams to minimize medication errors and enhance patient outcomes, and a proactive medication management in healthcare.