For medication orders, “fuzzy matching” is fuzzy illogical
The 2018 Epic upgrade released last year has incorporated “fuzzy matching” (also referred to as “fuzzy logic”) into its new platform. Simply put, if you misspell a word (e.g., medications, other treatments such as lab tests) when entering orders, or a patient’s name when searching, fuzzy matching in Epic presents a list of what the system “thinks” you are searching for, which may not be an exact match. You must then select the correct medication, lab test, patient, or other intended word or name from on-screen listings of “near hits.” Seemingly, that would be helpful given that misspellings and missing letters are common reasons why a requested drug or patient does not appear on the screen. However, for medications, near hits for drug names are not safe. In fact, they can be downright dangerous if they lead to a practitioner selecting the wrong drug. Medication selection errors are frequent when similar drug names are presented in drop-down lists and computer screens, which occurs when the list of near hits is generated. These selection errors are often caused by confirmation bias, during which the practitioner fails to notice that the drug name is different than intended, or by simple human error in which the practitioner accidentally selects the drug name above or below the name he or she intended to select. In some cases, a practitioner may not realize that the generic name on the list does not match the intended brand name ordered, or vice versa.
To reduce the potential for such errors, Epic has advised customers to test the fuzzy matching functionality before use by entering the drug names on the ISMP List of Confused Drug Names, using typographical errors such as transposed or missing characters and misspellings. Users can then enter what Epic refers to as “stop words” to prevent them from being suggested by the fuzzy matching system. Unfortunately, users can only add 100 stop words to the system. The ISMP List of Confused Drug Names contains hundreds of name pairs that have been involved in errors or close calls that were reported to the ISMP National Medication Errors Reporting Program (ISMP MERP).
Some hospitals have conducted the suggested testing using the ISMP List of Confused Drug Names and found concerning matches—scary, in fact. For example, if you misspell daunorubicin as “dunorubicin,” the near hit list will contain both daunorubicin and doxorubicin. Also, fuzzy matching will present only formulary medications. So, if daunorubicin is non-formulary but doxorubicin is on formulary, only doxorubicin will be listed as an option, even though it might not be the intended drug. Some pharmacists have gone through most of the ISMP list and identified dozens of risk points. Here are a few examples that appeared on screens during testing (differences in formularies may result in different outcomes):
If you type “alaprazolam” instead of alprazolam, you get estradiol transdermal (Alora)
If you type “Arecept” instead of Aricept, you get Viracept
If you type “cyclosorine” instead of cycloserine, you get cyclosporine
If you type “Dilacar” instead of Dilacor (diltiazem), you get pilocarpine (Pilocar)
ISMP does not believe that fuzzy matching is currently safe for medication ordering. Fuzzy matching can be disabled for all search options, but not for medications only. It’s either on or off. As soon as possible, Epic should prevent automatic enabling of fuzzy matching, and should allow the disabling of fuzzy matching for medications only. For now, the use of fuzzy matching is a risk not worth taking.
No errors have been reported to ISMP yet, but it’s very early in the implementation phase for hospitals. If you are using this functionality, please report any errors to ISMP.