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.

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 level of underreporting from different institutions. However, it may provide valuable and useful information on the specific types of errors related to CPOE systems.

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Acknowledgments

The contributions of Elizabeth Dayton, M.S., are acknowledged.

Reprint Address

Dr. Zhan at the Agency for Healthcare Research and Quality, Rockville, MD 20850 ( czhan@ahrq.gov ).

This article is the result of an intramural research project conducted at AHRQ. No statement in this article should be construed as the official position of AHRQ or USP.

Table 1. Characteristics of Health Care Facilities in Analysis
Characteristics	No. (%)
Characteristics	CPOE^a Facility	Non-CPOE Facility
Total	120 (100)	339 (100)
General community hospital	61 (51)	297 (87)
Specialty hospital	4 (3)	19 (6)
Outpatient clinic	55 (46)	23 (7)
Ownership
Government: federal	98 (81)	43 (12)
Government: state, city, or county	2 (2)	50 (15)
Nongovernmental nonprofit	19 (16)	242 (72)
For profit	1 (1)	4 (1)
Number of beds
<50	30 (44)	78 (25)
5099	9 (13)	48 (14)
100199	15 (22)	77 (24)
200299	6 (8)	69 (21)
300399	3 (4)	23 (7)
≥400	6 (8)	29 (9)
Not reported	1 (1)	0 (0)

^aCPOE = computerized prescriber order entry.

Table 2. Number of Medication Errors by Severity Category
Category^a	No. (%) Inpatient Errors		No. (%) Outpatient Errors
Category^a	CPOE^b Facility	Non-CPOE Facility	CPOE Facility	Non-CPOE Facility
B	10,884 (58.8)	35,016 (34.2)	6,581 (60.3)	2,919 (42.5)
C	6,357 (34.0)	55,867 (54.5)	4,023 (36.9)	3,367 (48.9)
D	1,131 (6.1)	9,287 (9.1)	227 (2.1)	441 (6.4)
E	262 (1.4)	1,847 (1.8)	68 (0.6)	118 (1.7)
F	34 (0.2)	369 (0.4)	6 (0.1)	27 (0.4)
G	2 (0.01)	25 (0.02)	1 (0.01)	3 (0.04)
H	1 (0.005)	37 (0.04)	0 (0)	2 (0.03)
I	5 (0.03)	15 (0.01)	0 (0)	0 (0)
Total	18,676 (100)	102,463 (100)	10,906 (100)	6,877 (100)

^aCategory B = an error occurred, but the error did not reach the patient, category C = an error occurred and reached the patient but did not cause harm, category D = an error occurred and reached the patient and required monitoring to confirm that it resulted in no harm to the patient or required intervention to preclude harm, category E = an error occurred that may have contributed to or resulted in temporary harm to the patient and required intervention, category F = an error occurred that may have contributed to or resulted in temporary harm to the patient and required initial or prolonged hospitalization, category G = an error occurred that may contributed to or resulted in permanent patient harm, category H = an error occurred that required intervention necessary to sustain life, category I = an error occurred that may have contributed to or resulted in the patient's death.
^bCPOE = computerized prescriber order entry.

Table 2. Number of Medication Errors by Severity Category
Category^a	No. (%) Inpatient Errors		No. (%) Outpatient Errors
Category^a	CPOE^b Facility	Non-CPOE Facility	CPOE Facility	Non-CPOE Facility
B	10,884 (58.8)	35,016 (34.2)	6,581 (60.3)	2,919 (42.5)
C	6,357 (34.0)	55,867 (54.5)	4,023 (36.9)	3,367 (48.9)
D	1,131 (6.1)	9,287 (9.1)	227 (2.1)	441 (6.4)
E	262 (1.4)	1,847 (1.8)	68 (0.6)	118 (1.7)
F	34 (0.2)	369 (0.4)	6 (0.1)	27 (0.4)
G	2 (0.01)	25 (0.02)	1 (0.01)	3 (0.04)
H	1 (0.005)	37 (0.04)	0 (0)	2 (0.03)
I	5 (0.03)	15 (0.01)	0 (0)	0 (0)
Total	18,676 (100)	102,463 (100)	10,906 (100)	6,877 (100)

Table 3. Medication Errors Reported by Facilities with and without Computerized Prescriber Order Entry (CPOE) ^a
Medication Error Type	Mean ± S.D. No. Errors		p
Medication Error Type	CPOE Facility	Non-CPOE Facility	p
Inpatient
Total errors	274 ± 549	320 ± 463	0.50
Errors per 100,000 doses	56 ± 123	55 ± 76	0.90
Harmful errors	7 ± 17	9 ± 13	0.30
Harmful errors per 100,000 doses	1 ± 1	2 ± 4	0.18
Outpatient
Total errors	101 ± 192	36 ± 99	<0.01
Errors per 100,000 doses	60 ± 99	57 ± 102	0.80
Harmful errors	1 ± 2	1 ± 2	0.10
Harmful errors per 100,000 doses	1 ± 2	2 ± 4	0.10

^aIncludes errors categorized as BI, based on medication errors submitted to Medmarx between May 1, 2003, and December 31, 2003.

Table 3. Medication Errors Reported by Facilities with and without Computerized Prescriber Order Entry (CPOE) ^a
Medication Error Type	Mean ± S.D. No. Errors		p
Medication Error Type	CPOE Facility	Non-CPOE Facility	p
Inpatient
Total errors	274 ± 549	320 ± 463	0.50
Errors per 100,000 doses	56 ± 123	55 ± 76	0.90
Harmful errors	7 ± 17	9 ± 13	0.30
Harmful errors per 100,000 doses	1 ± 1	2 ± 4	0.18
Outpatient
Total errors	101 ± 192	36 ± 99	<0.01
Errors per 100,000 doses	60 ± 99	57 ± 102	0.80
Harmful errors	1 ± 2	1 ± 2	0.10
Harmful errors per 100,000 doses	1 ± 2	2 ± 4	0.10

^aIncludes errors categorized as BI, based on medication errors submitted to Medmarx between May 1, 2003, and December 31, 2003.

Table 4. Characteristics of Medication Errors Related to Computerized Prescriber Order Entry ( n = 7029)
Item	No. (%) Errors
Severity category
A	4443 (63.2)
B	2248 (31.9)
C	300 (4.2)
D	30 (0.4)
E	8 (0.1)
Error type^a
Dosing errors	3436 (51.4)
Unauthorized drug	242 (3.6)
Wrong patient	231 (3.5)
Wrong time	117 (2.7)
Cause of error^b
Knowledge deficit	3158 (57.9)
Computer entry	2370 (43.4)
Abbreviations	1181 (21.6)
Calculations	1138 (20.9)
Factors contributing to medication errors^c
Distractions	803 (78.3)
Inexperienced staff	102 (10.0)
Workload increase	74 (7.2)
Computer system down	29 (2.8)

^a6579 reports identified one or more types.
^b5457 reports identified one or more causes.
^c1025 reports identified one or more factors.

Table 5. Common Medication Errors Associated with Computerized Prescriber Order Entry (CPOE)
Error	Example
Faulty computer interface	Provider ordered 21 tablets. Tablets supplied in single package. System accepted 21 packages, leading to overdose. Prescriber used shortcut key strokes "TID," intending three times a day dosing (T.I.D.). System did not recognize TID and failed to record order.
Miscommunication between CPOE and other systems	Prescriber incorrectly entered initial order. Recognized error and canceled original order and placed with second order. Original order printed on medication administration record, leading to duplicate dose. Prescriber intended to order aerosolized (respiratory therapy) treatment with tobramycin. Order printed in pharmacy but not in respiratory department. Treatments missed. Attending provider discharged patient. All orders immediately stopped, yet patient had not left unit and missed last dose. Different providers ordering same product for same patient (insulin formulations).
Failure to alert	Orders with planned future start day, but system failed to activate. Provider not prompted with warning of documented allergy information.
Wrong click or pick on the multiple- choice items on computer screen	Wrong product: Elimite instead of Elidel. Wrong strength: amoxicillin 500 mg instead of amoxicillin 250 mg. Wrong route: optic instead of otic.
Wrong patient	Provider selected John Smith, Sr., from the screen when John Smith, Jr., was the patient.

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