Dr. Gidi Stein recalls how disturbed he was when he heard about a malpractice case involving the death of a pediatric patient that was the result of a medication error. The child's doctor had accidentally selected the wrong medication from hundreds of drugs listed on the drop-down menu of a computerized order-entry form.
Stein, a professor of medicine and molecular imaging at Tel Aviv University in Israel, was dismayed that the tragic incident was described as an “unavoidable error.” With his background in software engineering and computational biology, he rejected that thinking as wrong-headed and dangerous. “Even if it's a one-in-a-million chance, hundreds could die like that,” he said. “It's completely unacceptable.”
In 2012, Stein co-founded an Israel-based company called MedAware. The firm offers a big-data software platform that integrates with a hospital's electronic health-record system to detect prescription errors before they happen. It draws from patterns in millions of patient records to flag medication-order outliers.
If a physician chooses a drug that doesn't match any condition in the patient's record or diverges from how other patients with similar histories have been treated, the discrepancy is flagged. The system blocks the drug order until the doctor confirms its accuracy or cancels and re-enters the order.
MedAware is catching the attention of safety leaders working to reduce medication errors, who say they aren't aware of other products taking this approach. “It's a nice added feature to what's out there,” said Matthew Grissinger, director of error reporting programs for the Institute for Safe Medication Practices, a Philadelphia-based not-for-profit focused on drug errors.
Medication errors are gaining more attention with the broader dissemination of EHRs and computerized prescription orders. A recent study in the journal BMJ Quality and Safety found that of more than 1 million medication errors reported to the U.S. Pharmacopeia MEDMARX reporting system between 2003 and 2010, more than 63,000 were related to computerized provider-order entry.