Role of computerized physician order entry systems in facilitating medication errors

• HIT Description: Computerized physician order entry More info...
  
• Purpose of Study: To identify and quantify the role of computerized physician order entry in facilitating prescription error risks.
  
• Years of study: 2002-2004
  
• Study Design: Qualitative and quantitative assessment.
  
• Outcomes: Medication errors.
  

• Settings: Urban tertiary teaching care hospital with 750 beds, 39,000 annual discharges, and a widely used CPOE system.
• Evaluation Method: Interviews, focus groups, expert interviews, surveys, and observation.
• Description: CPOE (TDS) operational from 1997-2004. Screens were monochromatic with pre-Windows interfaces (Eclipsys Corp). The system was used on almost all services and integrated with the pharmacy and nurses medication lists.
• Quality of Care and Patient Safety Outcome: 22 previously unexplored medication error sources were detected by qualitative and quantitative research. These were grouped by the authors as 1) Information errors generated by fragmentation of data and failure to integrate the hospital's several computer and information systems and 2) human-machine interface flaws reflecting machine rules that do not correspond to work organization or usual behaviors. Within the first category, identified errors include the assumed dose information, meaning that the CPOE displays dosages based on the pharmacy's warehousing and purchasing decisions, not clinical guidelines, yet 73% of house staff reported using CPOE displays to determine low doses for medications they did not usually prescribe. A second example of the first group of errors was antibiotic renewal failure which occurred because of a lack of coordination among information systems, leading to gaps in therapy because antibiotics are generally approved for three days. 83% of house staff observed gaps in antibiotic