Role of ComputerizedPhysician Order Entry Systemsin Facilitating Medication Errors
Ross Koppel, PhDJoshua P. Metlay, MD, PhD Abigail Cohen, PhDBrian Abaluck, BS A. Russell Localio, JD, MPH, MSStephen E. Kimmel, MD, MSCEBrian L. Strom, MD, MPH
DVERSE DRUG EVENTS
Prescrib-ing errors are the most frequentsource.
Computerized physician or-der entry (CPOE) systems are widelyviewedascrucialforreducingprescrib-ingerrors
andsavinghundredsof billions in annual costs.
Comput-erized physician order entry systemadvocates include researchers, clini-cians, hospital administrators, phar-macists, business councils, the Insti-tute of Medicine, state legislatures,health care agencies, and the lay pub-lic.
These systems areexpected to become more prevalent inresponsetoresidentworking-hourlimi-tations and related care discontinui-ties
andwillsupposedlyoffsetcauses(eg, job dissatisfaction) and effects(eg, ADEs) of nursing shortages.
Such a system is increasingly recom-mendedforoutpatientpractices(
).Adoption of CPOE perhaps gath-ered such strong support because itspromise is so great, effects of medica-
See also pp 1223 and 1261.
DepartmentofSociology(DrKop-pel), Department of Medicine, Cardiovascular Divi-sion (Dr Kimmel) and General Medicine Division (DrsMetlay and Strom), Center for Clinical Epidemiologyand Biostatistics (Drs Koppel, Metlay, Cohen, Kim-mel, and Strom and Mr Localio), Department of Bio-statisticsandEpidemiology(DrsMetlay,Kimmel,andStrom and Mr Localio), Department of Pharmacol-ogy (Dr Strom), Center for Education and Researchin Therapeutics (Drs Metlay and Strom and Mr Lo-calio), University of Pennsylvania School of Medicine(MrAbaluck),Philadelphia;andCenterforHealthEq-uity Research and Promotion, Department of Veter-ans Affairs, Philadelphia (Dr Metlay).
Ross Koppel, PhD, Center for ClinicalEpidemiologyandBiostatistics,Room106,Block-ley Hall, School of Medicine, University of Pennsylva-nia,Philadelphia,PA19104(firstname.lastname@example.org).
Hospitalcomputerizedphysicianorderentry(CPOE)systemsarewidelyre-garded as the technical solution to medication ordering errors, the largest identifiedsource of preventable hospital medical error. Published studies report that CPOE re-duces medication errors up to 81%. Few researchers, however, have focused on theexistence or types of medication errors facilitated by CPOE.
Design, Setting, and Participants
We performed a qualitative and quantitativestudy of house staff interaction with a CPOE system at a tertiary-care teaching hos-pital (2002-2004). We surveyed house staff (N=261; 88% of CPOE users); con-ducted 5 focus groups and 32 intensive one-on-one interviews with house staff, in-formation technology leaders, pharmacy leaders, attending physicians, and nurses;shadowed house staff and nurses; and observed them using CPOE. Participants in-cluded house staff, nurses, and hospital leaders.
Main Outcome Measure
Examples of medication errors caused or exacerbatedby the CPOE system.
We found that a widely used CPOE system facilitated 22 types of medica-tion error risks. Examples include fragmented CPOE displays that prevent a coherentview of patients’ medications, pharmacy inventory displays mistaken for dosageguidelines, ignored antibiotic renewal notices placed on paper charts rather than inthe CPOE system, separation of functions that facilitate double dosing and incompat-ible orders, and inflexible ordering formats generating wrong orders. Three quartersof the house staff reported observing each of these error risks, indicating that theyoccur weekly or more often. Use of multiple qualitative and survey methods identi-fied and quantified error risks not previously considered, offering many opportunitiesfor error reduction.
In this study, we found that a leading CPOE system often facilitatedmedication error risks, with many reported to occur frequently. As CPOE systems areimplemented, clinicians and hospitals must attend to errors that these systems causein addition to errors that they prevent.
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