Physicians Failed to Write Flawless Prescriptions When Computerized Physician Order Entry System Crashed

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This is a review of a CPOE study conducted in Taiwan and published in Clinical Therapeutics in 2015.


The authors suggest that over dependence on technology can result in unintended medication errors and affect physicians' prescription writing skills. This study assessed the completeness, legibility, and accuracy of physicians' handwritten prescriptions during an unintentional crash of a long-running CPOE system at a large hospital. [1]


The CPOE failure occurred in 2010 in a large hospital because of a hardware problem. The downtime lasted 3.5 hours. The analysis of a handwritten prescription was divided in 2 parts:(1) patient's and prescriber's data; and (2) drug data. Treatment decisions were not analyzed.


The study analyzed 1418 prescriptions with 3805 medications. The authors were unable to find a prescription that had all necessary fields filled in. For patient's and prescriber's data, only 4.5% of prescriptions fulfilled the criteria of completeness, legibility, and accuracy. For drug data, only 0.4% of prescriptions fulfilled the same criteria.


The study cites the following possible reasons for unsatisfactory quality of prescriptions:

  • Physicians had forgotten how to hand-write prescriptions.
  • Physicians had never been trained to hand-write prescriptions.
  • Insufficient time to hand-write prescriptions.
  • There was also poor preparation for the system downtime.

The authors believe it is impractical to train physicians to hand-write prescriptions for such rare event. They suggest a stand-alone e-prescribing software with automatic daily updates of medical records would be a better solution.


I believe standing orders on paper would be a better solution. This is what we have at my workplace, and it has been working well for us. Out standing orders match physician order sets in CPOE.


  1. Hsu, C., Chou, C., Chen, T., Ho, C., Lee, C., & Chou, Y. (2015). Physicians failed to write flawless prescriptions when computerized physician order entry system crashed. Clinical Therapeutics, 37(5), 1076-1080.

Additional Resource

Additional article on overdependence on technology and CPOE Campbell, et. al. 2007

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