The vulnerabilities of computerized physician order entry systems: a qualitative study

From Clinfowiki
Jump to: navigation, search


  1. To test the vulnerabilities of various currently used computerized physician order entry systems (CPOEs) to different types of medication errors.
  2. To collect essential information for qualitative analysis that can help understand effective tactics and improve design and usability of CPOEs.


The following is a summary of methods used in this investigation [1].

  • Reviewed a random sample of 63040 medication error reports from the US Pharmacopeia (USP) MEDMARX reporting system.
  • CPOE-contributed errors.
  • Capable to be tested in current CPOE systems.
  • To identify interface design, usability and workflow related issues.


  • CPOE systems often failed to detect and prevent important medication errors.
  • Variations of the means of alert generation.
  • High frequency of confused alerts.
  • Unrelated warning display with current erroneous entry.
  • Delayed warnings for dangerous drug-drug interactions that did not display at the time of order entry.
  • Lack of clinical decision support (CDS) protections.
  • Unclear wording for warnings in some CPOEs.


  • High variability among different CPOE systems.
  • Healthcare organizations are probably not getting all the safety benefits that they presumably should have by using CPOE plus CDS.
  • To change this scenario, design and implementation of an appropriately designed CDS system to improve effectiveness and usability of current CPOE systems could be one of effective tactics. In addition, human factors need to be carefully considered in this hybrid system as well.

Related Articles


  1. Slight, S. P., Eguale, T., Amato, M. G., Seger, A. C., Whitney, D. L., Bates, D. W., & Schiff, G. D. (2015). The vulnerabilities of computerized physician order entry systems: a qualitative study. Journal of the American Medical Informatics Association: JAMIA.