Impact of Emerging Technologies on Medication Errors and Adverse Drug Events

Eyal Oren, Ellen R. Shaffer, B. Joseph Guglielmo


Am J Health Syst Pharm. 2003;60(14) 

In This Article


While a number of new technologies have been recommended in an effort to reduce medical errors and ADEs, we found few studies that confirmed such an association.

Originally described in 1970, CPOE has been promoted as a technology that improves the quality of a medical information management system.[44] CPOE is said to provide process improvement; increased accuracy and legibility of the order; support of institution-specific recommendations; integration of clinical decision support into the order-entry process; optimization of physician, nurse, and pharmacist time; drug allergy checks; and identification of drug interactions and incorrect dosages. Detailed reviews of these benefits have been published.[27,45] CPOE specifically has been cited as one of the most effective measures for reducing medication errors.[46] It has been estimated that CPOE implementation at all nonrural hospitals in the United States could prevent over 500,000 serious medication errors each year.[47]

While some medical centers have successfully implemented CPOE systems (e.g., Brigham Integrated Computing System at Brigham and Women's Hospital, Boston, MA; Technicon Data System at New York University Medical Center and the University of Virginia Health System; Regenstrief Medical Center, Indianapolis, IN; HELP Clinical Information Management System at LDS Hospital, Salt Lake City, UT; and the Veterans Affairs Health System), most institutions have not. Studies have provided a wide range of estimates regarding the extent to which CPOE is currently used. One survey published in 1998 revealed that two thirds of all hospitals did not have CPOE in place.[48] Furthermore, physicians generally were not mandated to use the system at those institutions utilizing CPOE. At only 20% of hospitals were >50% of physicians using CPOE. Another survey found that less than 7% of surveyed hospitals used CPOE.[49] However, a survey of pharmacy directors determined that 13% of hospitals used CPOE, with 27% being in the process of obtaining such a system.[50] Of 241 hospitals responding to a survey published in 2002, only 3.3% were using CPOE.[51]

Our results confirm our belief that very few controlled studies have evaluated the impact of CPOE on patient outcomes. Even fewer have assessed the appropriateness of use of CPOE. The low rate of utilization of CPOE may be due to a number of factors, including the cost of implementation (in 1992 at Brigham and Women's Hospital, approximately $1.9 million for development and $500,000 for maintenance per year[50]; commercial systems may cost significantly more). In addition, institutional cultural barriers[52,53] and logistical challenges, such as training users, installing and upgrading equipment, and implementation, all likely contribute to slow transition to CPOE.[27,45,53]

All studies we included in this review evaluated CPOE systems that were developed internally, as opposed to those available commercially. The transferability of these systems from one institution to another has not been well studied. Some studies of CPOE[28] and ADMs[18] suggest that these technologies may not be used as intended. The widespread overrides of ADMs and CPOEs suggest that inappropriate use may affect patient safety.

ADMs have replaced the traditional unit dose cassette system in many institutions. ADMs allow medications to be stored on nursing units and be retrieved quickly and conveniently. The unit dose system has been criticized for delays in delivery of first doses for new orders, for providing more doses than necessary, and other problems.[31] ADMs, in contrast, are touted for dispensing only to a specific patient (as per the patient medication profile), improving medication availability, increasing the efficiency of drug dispensing and billing, and increasing time for patient care. Additionally, if linked with point-of-care bar-coding and information systems, ADMs have been proposed to decrease medication errors by ensuring an electronic match between the physician-ordered medication and the corresponding administered medication.[13]

In our review, five studies observed a decrease in medication errors associated with ADMs. However, considerable interuser variability in the reduction of medication errors has been documented.[33] Furthermore, while the observed differences in medication errors between unit dose and automated systems are statistically significant, they often are of low magnitude. Whether nursing overrides should be permitted remains controversial. Cost is an additional consideration in the implementation of ADMs. In 1995, the cost of implementation was estimated to be $1.28 million over five years for 10 acute care and 4 critical care units.[54] A 1999 pharmacy practice survey indicated that only 38% of responding hospitals used ADMs.[49]

Bar coding has the potential to improve patient safety from a number of perspectives, ranging from accurate patient identification to correct medication use and improved medical record keeping.[55] The technology can ensure that the appropriate drug is being dispensed and administered and accurately records when the drug is received and administered by the nurse.

It has been suggested that bar coding be implemented for medications, blood products, devices, and patients.[14] For example, by using a wireless device, bar codes can be scanned on a nurse identification badge, a patient's wristband, and the medication itself to confirm the correct patient, medication, and administration.[16] This technology is promising and may be an improvement over conventional wristbands, for which error rates as high as 5.5% have been reported.[56]

Bar coding has also been successfully integrated into specimen-handling procedures in laboratories.[57] Orders can be automatically sent to analyzers, where they can be appropriately processed without additional sorting and labeling of samples. Bar coding has been proposed for areas ranging from the microbiology laboratory to the emergency department.[40]

Bar coding reduces error rates in industrial manufacturing, identification, inventory tracking, and shipping. However, pharmaceutical manufacturers have not agreed on a standard approach to the implementation of bar coding, delaying widespread implementation.[13] Additionally, bar coding may require changes in packaging, as well as additional computer programming for unusual doses. Consequently, potential increases in costs associated with repackaging and relabeling in the pharmacy must be considered.

While bar coding experimentally improves both the speed and accuracy of data entry, few other "real-life" data are available to clarify its role. In particular, studies evaluating point-of-care systems that verify patient and drug information were not found. Meyer et al.[41] estimated implementation costs at $119,516 annually (in 1991 dollars), with the per dose cost of bar-code labeling estimated at $0.0273. Few studies have examined the application and outcomes associated with bar coding in the hospital. Further evaluation is warranted.

CMARs potentially allow integration of drug purchasing, distribution, and patient information into a comprehensive database. Potential benefits include consistency in medication documentation, clear records of administration, consistency of directions, and precise dosage information.[58] A computerized system also potentially improves productivity through printouts of fill lists, labels, and utilization reports and by allowing pharmacists and nurses to focus on patient care.

CMARs may result in unexpected increases in personnel time, multiple entries for a medication order to appear correctly on the MAR, and different interpretations of orders by pharmacists and nurses.[59] These possible lapses in appropriate use have not been examined. No studies confirm that CMARs improve patient outcomes through the reduction of errors or improvements in work processes.

Despite strong recommendations to adopt new technologies to reduce medication errors and ADEs, few studies confirm such benefits. Furthermore, very few investigations have evaluated the appropriateness of use of such technologies. Reasons for the lack of widespread use may include the difficulty of transferability of the technology, human and organizational factors, and logistical challenges. Costs associated with the development and maintenance of new technologies potentially range into the millions of dollars per year. Before a new technology can be recommended for broad use, the technology should be demonstrated to result in a reduction in medication errors and ADEs and have been evaluated for appropriateness of use. Furthermore, these findings should be demonstrated in a variety of settings in order to confirm the extent to which they are transferable to multiple institutions. Our results suggest that only a few studies have examined the impact of these technologies on patient outcomes. Those that have been conducted have been concentrated in a few institutions. When appropriateness of use has been evaluated, substantial deviations by staff from intended procedures have been identified.

Automated devices and systems have demonstrated the potential to perform parts of the medication-use process in a more standardized and reliable manner and with less error than with manual systems. These findings are welcome, considering the complexity of the medical care system, the confirmed harm due to preventable medication errors, and the failure of punitive measures to alter human behaviors that result in errors. However, organizational and human factors cannot be entirely eliminated from patient care. Technologies are only as successful as they are usable, and no battery of technologies is likely to compensate entirely for cumbersome workflow and human stress and fatigue. Understanding the bridge between effectiveness in controlled circumstances and efficacy in the real world in which technologies are applied will be critical to optimizing benefits to patients, providers, and the health care system.


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