Evaluation of causes and frequency of medication errors during information technology downtime

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Clinical information systems have shown significant benefits in terms of quality of care and patient safety. However, it is not completely devoid of errors. Although computerized physician order entry (CPOE) has shown a significant decrease in medication errors, there are still instances where fatal errors have resulted using these systems. Medication errors in CIS can be due to various factors, such as entering data or instruction in the wrong field and disruption in flow of information due to system malfunctions and/or system downtime. In this article authors specifically report medication errors that are caused due to system downtime. [1]


The authors conduct a survey of 78 hospitals in Ohio, in which survey participants were directly involved in supporting and maintaining information based technologies.


Survey response rate was 41%. Two main reasons for uncontrollable downtime was computer virus in eight hospitals and natural disaster in 4 hospitals. A total of 39 medication errors were reported in a 12-month period and in CPOE and the worst of which required intervention to prevent patient harm. It is worth noting that all the hospitals had some kind of a back up system to provide support in downtime.


Despite having back up plans in place to ensure smooth operation during downtime, medication errors were caused and in some cases it extended the length of hospital stay and in others needed intervention to prevent patient harm. This suggests that further efforts are needed to address downtime workflow.


The uniqueness of this article is that it studies medication errors specifically during information technology downtime. It is noteworthy that all the hospitals had downtime plans and some back up system to provide patient care during downtime despite which errors occurred. This further emphasizes that having a back up plan is not sufficient. It is essential to test the back up plans and continuously modify it to obtain better results.


  1. Koppel, 2005. IT Role of computerized physician order entry systems in facilitating medication errors. http://www.ncbi.nlm.nih.gov/pubmed/15755942