Role of Computerized Physician Order Entry Systems in Facilitating Medical Errors

Department of Sociology, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia 19104 USA.
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 04/2005; 293(10):1197-203. DOI: 10.1001/jama.293.10.1197
Source: PubMed


Hospital computerized physician order entry (CPOE) systems are widely regarded as the technical solution to medication ordering errors, the largest identified source of preventable hospital medical error. Published studies report that CPOE reduces medication errors up to 81%. Few researchers, however, have focused on the existence or types of medication errors facilitated by CPOE.
To identify and quantify the role of CPOE in facilitating prescription error risks.
We performed a qualitative and quantitative study of house staff interaction with a CPOE system at a tertiary-care teaching hospital (2002-2004). We surveyed house staff (N = 261; 88% of CPOE users); conducted 5 focus groups and 32 intensive one-on-one interviews with house staff, information technology leaders, pharmacy leaders, attending physicians, and nurses; shadowed house staff and nurses; and observed them using CPOE. Participants included house staff, nurses, and hospital leaders.
Examples of medication errors caused or exacerbated by the CPOE system.
We found that a widely used CPOE system facilitated 22 types of medication error risks. Examples include fragmented CPOE displays that prevent a coherent view of patients' medications, pharmacy inventory displays mistaken for dosage guidelines, ignored antibiotic renewal notices placed on paper charts rather than in the CPOE system, separation of functions that facilitate double dosing and incompatible orders, and inflexible ordering formats generating wrong orders. Three quarters of the house staff reported observing each of these error risks, indicating that they occur weekly or more often. Use of multiple qualitative and survey methods identified and quantified error risks not previously considered, offering many opportunities for error reduction.
In this study, we found that a leading CPOE system often facilitated medication error risks, with many reported to occur frequently. As CPOE systems are implemented, clinicians and hospitals must attend to errors that these systems cause in addition to errors that they prevent.

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    • "For example, Linder et al. (2007) using cross sectional data for his study found no association between the use of electronic health records and quality of ambulatory care. Similarly, Koppel et al. (2005) using cross sectional data found that the use of CPOE facilitated 22 types of medication error risks. Numerous operations management studies have documented the lengthy learning curve between the technology adoption and improvements in performance (Boyer, 1999). "
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