Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems
Contents
Abstract
- IMPORTANCE:Medication computerised provider order entry (CPOE) has been shown to decrease errors and is being widely adopted. However, CPOE also has potential for introducing or contributing to errors.
- OBJECTIVES:
The objectives of this study are to (a) analyse medication error reports where CPOE was reported as a 'contributing cause' and (b) develop 'use cases' based on these reports to test vulnerability of current CPOE systems to these errors.
- METHODS:
A review of medication errors reported to United States Pharmacopeia MEDMARX reporting system was made, and a taxonomy was developed for CPOE-related errors. For each error we evaluated what went wrong and why and identified potential prevention strategies and recurring error scenarios. These scenarios were then used to test vulnerability of leading CPOE systems, asking typical users to enter these erroneous orders to assess the degree to which these problematic orders could be entered.
- RESULTS:
Between 2003 and 2010, 1.04 million medication errors were reported to MEDMARX, of which 63 040 were reported as CPOE related. A review of 10 060 CPOE-related cases was used to derive 101 codes describing what went wrong, 67 codes describing reasons why errors occurred, 73 codes describing potential prevention strategies and 21 codes describing recurring error scenarios. Ability to enter these erroneous order scenarios was tested on 13 CPOE systems at 16 sites. Overall, 298 (79.5%) of the erroneous orders were able to be entered including 100 (28.0%) being 'easily' placed, another 101 (28.3%) with only minor workarounds and no warnings.
- CONCLUSIONS AND RELEVANCE:
Medication error reports provide valuable information for understanding CPOE-related errors. Reports were useful for developing taxonomy and identifying recurring errors to which current CPOE systems are vulnerable. Enhanced monitoring, reporting and testing of CPOE systems are important to improve CPOE safety. [1]
Summary
Introduction
Once thought to be a highly error resistant, Computerised Provider Order Entry (CPOE) has begun to have documented errors that have not been seen before. Due to these errors, the FDASIA recommended developing approaches for error compilation. SInce 2003, when the USP error recording system was able to record CPOE errors, it has become the third leading cause of errors being submitted.It is the goal of this article to analyze data from 10,000 of these CPOE reported errors and assess vulnerabilities of leading CPOE systems.
Methods
Phase 1
THe MEDMARX system was searched for CPOE errors from Jan 2003 to Apr 2010. 63,040 queries were collected from a total of 1.04 million reports. These reports were then reviewed and coded according to the National Coordination Council for Medication Error Reporting and Prevention.
Phase 2
A weighted scoring system was used based on error frequency, severity, generalisability, and testability. Based on these scores 21 test scenarios were choosen. The scenarios were then tested on test patients at a sample of leading vendor and homegrown CPOE systems, and the ease at which these orders were entered was recorded.
