Healthcare Quarterly

Healthcare Quarterly 10(Sp) November 2006 : 83-83.doi:10.12927/hcq..18506

Commentary: The Benefits and Impacts of the MOE/MAR Implementation: A Quantitative Approach

Denis Protti


This paper describes how UHN was able to determine if the MOE/MAR project accomplished its stated objectives of improving patient safety and the medication ordering and processing cycle. Though the authors qualify that the benefits study was not intended to measure adverse drug events or to replicate the 2004 study by Baker et al., the findings do add new evidence that MOE/MAR does indeed reduce ordering and transcription errors and reduce medication incidences.
These UHN findings are particularly significant, since other recent evidence suggests that, despite the growing use of error reporting tools, the healthcare industry is inexperienced in receiving, understanding and analyzing these reports. A recent Johns Hopkins study (Miller et al. 2006) found that, despite clear imperfections in the data captured, medication error reporting tools are effective as a means of collecting reliable information on errors rapidly and in real time. Their data suggest that administration errors are at least as common as prescribing errors in children.

Miller et al. (2006) found that, of the 1,010 medication errors reviewed, 30% were prescribing errors, 24% were dispensing errors, 41% were administration errors and only 6% involved medication administration records (MAR). About one-third of the medication error reports needed to have the subtype of error reclassified; 59% of these involved the reporter choosing the non-descript "other" category on the reporting tool (such as "prescribing other"), which was able to be reclassified by expert review. The overall distribution of error type categories did not change significantly with expert review, although only MAR errors were underreported by the reporters. The most common medications were anti-infectives (17%), pain/sedative agents (15%), nutritional agents (11%), gastrointestinal agents (8%) and cardiovascular agents (7%).

Whenever the subject of errors comes up, one is reminded of Morgan's 2004 paper, "In Pursuit of a Safe Canadian Healthcare System." In it, he asked: Are Canadian patients safer today? Has the national rate of medical errors decreased? Are fewer hospitalized patients in Canada dying from medical errors? Are Canadians less likely to experience an adverse drug event in the outpatient setting? Is our growing home care delivery safe? Are diagnostic investigations being performed in a timely and effective manner? Are the right patients being treated with the right medications in the right dosages for the right duration? Are patients achieving the expected and desired outcomes?

The recent Johns Hopkins paper suggests that further research is needed, not only in the area of computerized physician order entry (CPOE) for children, but also on ways to make the dispensing and administration of medications safer. Undoubtedly, the same applies to the UHN and other adult hospitals introducing medication order entry and medical administration record systems. However, thanks to the efforts underway at UHN and other leading facilities, can we say that some of Morgan's questions are being answered?

About the Author(s)

Denis Protti is a Professor, School of Health Information Science, University of Victoria.


Miller, M.R. , J.S. Clark and CU Lehmann. 2006. "Computer Based Medication Error Reporting: Insights and Implications." Quality and Safety in Health Care 15: 208 - 13.

Morgan, M.W. 2004. "In Pursuit of a Safe Canadian Healthcare System." HealthcarePapers 5(3): 10 - 28.


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