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CPOE Facilitates Errors Study from 2005

CPOE Facilitates Errors Study from 2005

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Researchers including Ross Koppel publish a paper in the Journal of the American Medical Association highlighting 22 new problems that arise from the use of computerized provider order entry.
Researchers including Ross Koppel publish a paper in the Journal of the American Medical Association highlighting 22 new problems that arise from the use of computerized provider order entry.

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Published by: huffpostfund on Jun 30, 2010
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current as of April 23, 2009.Online article and related content http://jama.ama-assn.org/cgi/content/full/293/10/1197. 2005;293(10):1197-1203 (doi:10.1001/jama.293.10.1197)
Ross Koppel; Joshua P. Metlay; Abigail Cohen; et al.
Facilitating Medication ErrorsRole of Computerized Physician Order Entry Systems in
Topic collections
ErrorQuality of Care; Quality of Care, Other; Drug Therapy; Adverse Effects; Medication
the same issueRelated Articles published in
Performance and Patient Outcomes: A Systematic ReviewEffects of Computerized Clinical Decision Support Systems on Practitioner
Related Letters
Computerized Physician Order EntrySystems and Medication Errors
 at University of South Carolina on April 23, 2009www.jama.comDownloaded from 
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
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).
Corresponding Author:
Ross Koppel, PhD, Center for ClinicalEpidemiologyandBiostatistics,Room106,Block-ley Hall, School of Medicine, University of Pennsylva-nia,Philadelphia,PA19104(rkoppel@sas.upenn.edu).
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.
 JAMA. 2005;293:1197-1203
©2005 American Medical Association. All rights reserved.
(Reprinted) JAMA,
March 9, 2005—Vol 293, No. 10
 at University of South Carolina on April 23, 2009www.jama.comDownloaded from 
tion error so distressing, circum-stancesofmedicationerrorsoprevent-able,andstudiesofCPOEpreliminaryyet so positive.
Studies of CPOE,however, are constrained by its com-parative youth, continuing evolution,need to focus on potential rather thanactual errors, and limited dissemina-tion (in 5% to 9% of US hospitals).
Two critical studies
examined dis-tinctions between reductions in pos-sible ADEs vs actual reductions inADEs; the former are well docu-mented and often cited, but the latterare largely undocumented and un-known.StudiesofCPOEefficacy(17%to 81% error reduction) usually focusonitsadvantages
andaregen-erally limited to single outcomes, po-tentialerrorreduction,orphysiciansat-isfaction.
OftenstudiescombineCPOE and clinical support systems intheir analyses.
suggestedsomewaysthatCPOEmightcontributetomedica-tionerrors(eg,ignoredfalsealarms,com-putercrashes,ordersinthewrongmedi-calrecords).Severaldecadesofhuman-factorsresearch,moreover,highlightedunintended consequences of techno-logic solutions, with recent discussionson hospitals.
 We undertook a comprehensive,multimethod study of CPOE-relatedfactors that enhance risk of prescrip-tion errors.
 We performed a quantitative andqualitative study incorporating struc-tured interviews with house staff,pharmacists, nurses, nurse-managers,attending physicians, and informa-tion technology managers; real-timeobservations of house staff writingorders, nurses charting medications,and hospital pharmacists reviewingorders; focus groups with house staff;and written questionnaires adminis-tered to house staff. Qualitativeresearch was iterative and interactive(ie, interview responses generatednew focus group questions; focusgroup responses targeted issues forobservations).
 Westudiedamajorurbantertiary-careteachinghospitalwith750beds,39000annual discharges, and a widely usedCPOE system (TDS) operational therefrom 1997 to 2004. Screens were usu-ally monochromatic with pre-Win-dowsinterfaces(EclipsysCorp,BocaRa-ton,Fla).Thesystemwasusedonalmostallservicesandintegratedwiththephar-macy’s and nurses’ medication lists.ThisstudywasapprovedbytheUni-versityofPennsylvaniainstitutionalre-view board. The researchers were notinvolved in CPOE system design, in-stallation, or operation.
Data Collection
Intensive One-on-One House Staff Interviews
.Todevelopourinitialques-tions, we conducted 14 one-on-onehouse staff interviews. An experi-encedsociologist(R.K.)conductedtheopen-ended interviews, focusing onstressors and other prescribing-errorsources(meaninterviewtime,26min-utes; range,14-66 minutes).
Focus Groups
. We conducted 5 fo-cus groups with house staff on sourcesofstressandprescribingerrors,moder-atedbyanexperiencedsociologist(R.K.)andaudiorecorded.Participantswerere-imbursed $40 (average group size, 10;range, 7-18; and average length, 1.75hours; range, 1.4-2 hours).
Expert Interviews
. We interviewedthe surgery chair, pharmacy and tech-nology directors, clinical nursing di-rector, 4 nurse-managers, 5 nurses, aninfectiousdiseasefellow,and5attend-ing physicians. All interviews, except1,wereprivatelyconductedbythesameinvestigator (R.K.).
Shadowing and Observation
. Dur-ing a discontinuous 4-month period(2002-2003),weshadowed4housestaff,3attendingphysicians,and9nursesen-gagedinpatientcareandCPOEuse.Weobserved 3 pharmacists reviewing or-ders. The researcher (R.K.) wore a fac-ulty identification badge. Observationnotes were freehand but guided by theinterview findings.
.From2002tothepresent,wedistributed structured, self-adminis-
Box. Advantages of CPOE Systems Compared With Paper-BasedSystems
Free of handwriting identification problemsFaster to reach the pharmacyLess subject to error associated with similar drug namesMore easily integrated into medical records and decision-support systemsLess subject to errors caused by use of apothecary measuresEasily linked to drug-drug interaction warningsMore likely to identify the prescribing physicianAble to link to ADE reporting systemsAble to avoid specification errors, such as trailing zerosAvailable and appropriate for training and educationAvailable for immediate data analysis, including postmarketing reportingClaimed to generate significant economic savings With online prompts, CPOE systems canLink to algorithms to emphasize cost-effective medicationsReduce underprescribing and overprescribingReduce incorrect drug choices
Abbreviations: ADE, adverse drug event; CPOE, computerized physician order entry.
March 9, 2005—Vol 293, No. 10
©2005 American Medical Association. All rights reserved.
 at University of South Carolina on April 23, 2009www.jama.comDownloaded from 

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