Potential Benefits and Problems With Computerized Prescriber Order Entry

Analysis of a Voluntary Medication Error-Reporting Database

Chunliu Zhan; Rodney W. Hicks; Christopher M. Blanchette; Margaret A. Keyes; Diane D. Cousins


Am J Health Syst Pharm. 2006;63(4):353-358. 

In This Article

Abstract and Introduction


Purpose: The potential benefits and problems associated with computerized prescriber-order-entry (CPOE) systems were studied.
Methods. A national voluntary medication error-reporting database, Medmarx, was used to compare facilities that had CPOE with those that did not have CPOE. The characteristics of medication errors reportedly caused by CPOE were explored, and the text descriptions of these errors were qualitatively analyzed.
Results: Facilities with CPOE reported fewer inpatient medication errors and more outpatient medication errors than facilities without CPOE, but the statistical significance of these differences could not be determined. Facilities with CPOE less frequently reported medication errors that reached patients (p < 0.01) or harmed patients (p < 0.01). More than 7000 CPOE-related medication errors were reported over seven months in 2003, and about 0.1% of them resulted in harm or adverse events. The most common CPOE errors were dosing errors (i.e., wrong dose, wrong dosage form, or extra dose). Both quantitative and qualitative analyses indicate that CPOE could lead to medication errors not only because of faulty computer interface, miscommunication with other systems, and lack of adequate decision support but also because of common human errors such as knowledge deficit, distractions, inexperience, and typing errors.
Conclusion: A national, voluntary medication error-reporting database cannot be used to determine the effectiveness of a CPOE system in reducing medication errors because of the variability in the number of reports from different institutions. However, it may provide valuable information on the specific types of errors related to CPOE systems.


The process of medication use is a continuum of activities involving multiple health care professionals and multiple steps (i.e., prescribing, transcribing, dispensing, administering, and monitoring), thereby creating multiple opportunities for error. Errors are especially likely to occur at the prescribing stage for many reasons, such as a prescriber's inadequate knowledge of medications, nonadherence to policies and procedures, memory lapses, nomenclature-related confusion, miscalculation and errors in unit expression, faulty patient identity checks, illegible handwriting, faulty ordering forms, and inadequate or incorrect patient information.[1,2,3,4,5]

Computerized prescriber order entry (CPOE) entails the prescriber's use of computer assistance to directly enter medical orders (e.g., laboratory, radiology, or medication) from a desktop computer or a mobile device such as a personal data assistant.[6] CPOE systems offer real-time access to patient records and often offer clinical decision support. By design, CPOE would eliminate illegible handwriting; avoid transcription errors; improve response time, accuracy, and completeness; and improve coordination and continuity of care.[7] In addition, decision-support systems help prescribers avoid errors by alerting them to improper doses, allergies, contraindications, drug duplication, drug-drug interactions, and other potential risks.[1,3,4,8,9] Some CPOE systems are linked to the medication administration record, which helps to reduce administration errors.[10]

Empirical evidence about the potential of CPOE systems to reduce medication errors has been limited. Pharmacists at a 700-bed academic medical center in Chicago reviewed a week's worth of medication error orders and determined that, of the 1111 errors, 64.4% could have been prevented by a CPOE system.[2] A study comparing medication errors six months before and nine months after implementation of a CPOE system in a large tertiary care hospital suggested that CPOE resulted in a 55% decrease in medication errors.[11] With the addition of decision-support features to the CPOE system, medication errors were reduced by 81%.[12] Nevertheless, CPOE systems introduce new errors. A recent study observed the use of CPOE at a tertiary care teaching hospital by physicians and other staff and identified 22 types of medication error risks associated with the system.[13]

The primary objective of this study was to assess the potential benefits and problems associated with CPOE using a voluntary medication error-reporting system, Medmarx, sponsored by the United States Pharmacopeia (USP). The past five years have witnessed substantial national efforts in voluntary medical error-reporting systems, but how these systems contribute to safety improvement is debated.[14,15] This study also attempted to explore the potential value and proper use of voluntary error reporting in patient safety research.


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