Computerized Physician Order Entry: Fallible, Not Foolproof

Linda Timm Wagner, PharmD; Charlotte A. Kenreigh, PharmD


November 17, 2005

In This Article


The use of computerized physician order entry (CPOE) has increased since the Institute of Medicine issued its 1999 report, "To Err is Human," which described the scope of medical errors in the United States. CPOE is designed to decrease medication errors at the prescription stage, circumventing the need to decipher illegible handwriting. The technology often includes prompts and dosing calculators to make dosing safer and patient-specific. No paper transfer is required, so there is less chance for orders to be lost or incomplete. The benefits of CPOE seem endless, and many organizations have invested large sums of money in the hope that the technology will help reduce medication errors and increase patient safety.

However, although the use of CPOE will reduce a certain type of error, the system is not foolproof. As with other technologies, CPOE systems also have the potential to introduce new errors, breed a false sense of security, and shift attention away from other types of medication errors.

CPOE addresses errors of commission, but it does nothing to prevent errors of omission. In fact, the adoption of bar code systems and CPOE may actually represent "a distraction from solving the real systemic issue at the heart of 'failure to rescue.'... [A]t the core of the patient safety problem are the often invisible, unrecognized mistakes that happen, called 'errors of omission.'"[1] Thus, organizations need to adjust their focus and look at the broader picture.

Several articles addressing the use of CPOE have been published in the past year. Highlights from these articles are provided here.


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