Computerized Physician Order Entry: Fallible, Not Foolproof

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


November 17, 2005

In This Article

Rates of Adverse Drug Events

Although the introduction of CPOE has positively impacted medication use systems in many areas, reports of medication errors and adverse drug events (ADEs) have been linked to the computerized systems.[3,4,5] One study reviewed a random sample of electronic patient records at a Veterans Administration hospital over a 20-week period.[3] A total of 483 clinically significant ADEs were reported among 937 hospital admissions. Medication errors were linked to 27% of the ADEs, and 61% of the errors occurred during ordering. No transcription errors were evident, and only 1% were considered dispensing errors; 13% of the ADEs were associated with administration and 25% with monitoring.

The authors concluded that the high rate of errors demonstrated that improvements in computerized interventions were necessary.[3] Specifically, they noted that CPOE systems should address dosing, prophylaxis, and monitoring errors, and users of CPOE systems should customize the decision support pieces to address the most troublesome aspects of the medication administration process. This supports the call for greater decision support suggested by Miller and colleagues.[2]

Another study examined house staff interactions with a CPOE system at a tertiary-care teaching hospital to identify and quantify the role of CPOE in facilitating prescription error risks.[4] The investigators found that the CPOE system facilitated 22 types of medication error risks. These risks were in part the result of fragmented CPOE displays, false interpretation of pharmacy inventory displays as dosing guidelines, inflexible ordering formats, gaps in antibiotic administration related to nonrenewal of stop orders, delayed ordering due to system unavailability, difficulty specifying medications that were not on the formulary, and lack of system flow between the pharmacy system (drug interactions) and the CPOE system. As with the VA study, the authors concluded that when CPOE systems are implemented, users must pay careful attention to errors that may occur as a result of the system itself.

It must be noted that the results of this study have been criticized because the particular CPOE system studied is now considered outdated, and because of a lack of interface between the CPOE system and an electronic medical record system.[6,7}] However, the study and the subsequent letters to the editor served as a springboard for others to comment on the role of CPOE and medication errors.

In fact, the Journal of Biomedical Informatics invited several experts to write commentaries about the house staff study.[8,9,10] For the most part, the commentaries supported the argument that current CPOE systems need improvements. The authors echoed others' cautions against being overly confident in the systems, pushing for ways to continually improve the technology. Bridging the gap between IT and the needs of healthcare providers and patients is essential.

The authors of the house staff study were given the opportunity to respond to the commentaries.[11] They welcomed the chance for this issue to be discussed freely, agreeing that CPOE systems will be central parts of future healthcare systems. They repeated their assertion that careful research is needed to guide the development of systems that will benefit rather than hinder medical practice.


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