COMMENTARY

Computerized Physician Order Entry: Fallible, Not Foolproof

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

Disclosures

November 17, 2005

In This Article

When an Error Occurs

What can organizations do to drill down the events that lead to an error stemming from the use of CPOE? A case study published in the Journal of the American Medical Informatics Association offers insight into how one organization analyzed a medication dosing error that occurred while a CPOE system was in place.[5]

The organization treated the event as a sentinel event and looked at the entire process in a detailed manner. As expected, a single breakdown was not found, but rather the convergence of several factors. These included physician errors in the use of the ordering system, the absence of automated safeguards to help prevent errors, and physician uncertainty as to how to handle an unusual ordering scenario. Learning from one organization's experiences could prevent serious errors in the future.

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