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Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors Ross Koppel, Joshua P. Metlay, et al.

Hospital computerized physician order entry (CPOE) systems are widely regarded as the technical solution to medication ordering errors, the largest identified source of preventable hospital medical error. Published studies report that CPOE reduces medication errors up to 81%. Few researchers, however, have focused on the existence or types of medication errors facilitated by CPOE. The authors undertook a comprehensive, multimethod study of CPOE-related factors that enhance risk of prescription errors.


Design They performed a quantitative and qualitative study incorporating structured interviews with house staff, pharmacists, nurses, nurse-managers, attending physicians, and information technology managers. The Qualitative research was iterative and interactive Setting They studied a major urban tertiary-care teaching hospital with 750 beds, 39000 annual discharges, and a widely used CPOE system (TDS) operational there from 1997 to 2004. Data Collection 1-Intensive One-on-One House Staff Interviews. 2-Focus Groups.3-Expert Interviews.4-Shadowing and Observation.5-Survey.


The study identified 22 previously unexplored medication-error sources that users report to be facilitated by CPOE. They group these as:

A-Information Errors: Fragmentation and Systems Integration Failure.

1- Assumed Dose Information. House staff often rely on CPOE displays to determine minimal effective or usual doses. The dosages listed in the CPOE display, however, are based on the pharmacy’s warehousing and purchasing decisions, not clinical guidelines. 2-Medication Discontinuation Failures Ordering new or modifying existing medications is usually a separate process from canceling (“discontinuing”) an existing medication. Without discontinuing the current dose, physicians can increase or decrease medication, add new but duplicative medication, and add conflicting medication. 3-Procedure-Linked Medication Discontinuation Faults. Procedures and certain tests are often accompanied by medications. If procedures are canceled or postponed, no software link automatically cancels medications. 4-Immediate Orders and Give-as-Needed Medication Discontinuation Faults. NOW (immediate) and PRN (give as needed) orders may not enter the usual medication schedule. Failure to chart or cancel can result in unintended medications on subsequent days or reordering (duplications) on the same day. 5-Antibiotic Renewal Failure Antibiotics are generally approved for 3 days. Before the third day, house staff should request continuation or modification. No warning is integrated into the CPOE system, and ordering gaps expand until noticed. Some unintentional “gaps” continue indefinitely because it is unknown whether antibiotics were intentionally halted. 6-Diluent Options and Errors A recent CPOE innovation requires house staff to specify diluents (e.g., saline solution) for administering antibiotics. Many house staff are unaware of impermissible combinations. 7-Allergy Information Delay CPOE provides feedback on drug allergies, but only after medications are ordered. 8-Conflicting or Duplicative Medications The CPOE system does not display information available on other hospital systems. For example, only the pharmacy’s computer provides drug interaction and lifetime limit warnings.

B-Human-Machine Interface Flaws: Machine Rules That Do Not Correspond to Work Organization or Usual Behaviors

1-Patient Selection It is easy to select the wrong patient file because names and drugs are close together, the font is small, names are grouped alphabetically and most critical here, patients’ names do not appear on all screens. 2-Wrong Medication Selection. A patient’s medication information is seldom synthesized on 1 screen. Up to 20 screens might be needed to see all of a patient’s medications, increasing the likelihood of selecting a wrong medication. 3-Unclear Log On/Log Off Physician scan order medications at computer terminals not yet “logged out” by the previous physician, which can result in either unintended patients receiving medication or patients not receiving the intended medication. 4-Failure to Provide Medications After Surgery. When patients under go surgery, CPOE cancels their previous medications. When surgeons order new or renewed medications, however, the orders are “suspended” (not sent to the pharmacy) until “activated” by postanesthesia-care nurses. But these “activations” still do not dispense medications. Physicians must reenter CPOE and reactivate each previously ordered medication. 5-Postsurgery “Suspended” Medications. Physicians ordering medications for postoperative patients whom they actually observe on hospital floors can be deceived by patients’ real location vs. patients’ computer-listed location. If patients were not logged out of postanesthesia care, the CPOE will not process medication orders, labeling them “suspended.” Physicians must renegotiate the CPOE and resubmit orders for patients to receive postsurgical medications. 6-Loss of Data, Time, and Focus When CPOE Is Nonfunctional. CPOE is shutdown for periodic maintenance, and crashes are common. Backup systems prevent loss of data previously entered. However, orders being entered when the system crashes are lost and cannot be reentered until the system is restarted. House staff reported that the 7-Sending Medications to Wrong Rooms When the Computer System Has Shut Down. When a patient is moved within the hospital during the system downtime. 8-Late-in-Day Orders Lost for 24 Hours. When patients leave surgery or are admitted late in the day, medications and laboratory orders might be requested for “tomorrow” at, for example, 7 AM. By the time the intern enters the orders, however, it might already be “tomorrow” (i.e., after midnight). Therefore, patients do not receive medications or tests for an extra day. 9-Role of Charting Difficulties in Inaccurate and Delayed Medication Administration. Nurses are required to record (chart) administration of medications contemporaneously. However, this requires time. 10-Inflexible Ordering Screens, Incorrect Medications.


In this study, it was found that a leading CPOE system often facilitated medication error risks, with many reported to occur frequently. As CPOE systems are implemented, clinicians and hospitals must attend to errors that these systems cause in addition to errors that they prevent.


The study conducted at only 1 hospital, examined only 1 CPOE system and the finding are not t from random house staff samples. So the errors discussed here may not be widely generalizable. Most of these CPOE facilitated errors can be easily corrected and avoided during the development and implementation of the system.

reviewed by Ahmed Mahmoud

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