CPOE May Increase Medication Error Risk

Published Online: Friday, April 1, 2005

A study, reported in the Journal of the American Medical Association (March 9, 2005) found that computerized physician order entry (CPOE) systems may do more harm than good. The researchers studied CPOE-related factors that increase the risk of prescription errors. They carried out a qualitative and quantitative study of house staff interactions with a CPOE system at a teaching hospital. They surveyed house staff (n = 261; 88% of CPOE users); conducted 5 focus groups and 32 thorough 1-on-1 interviews with house staff, information technology leaders, and pharmacy leaders; followed house staff and nurses; and watched them using CPOE.

The study found that CPOE facilitated 22 types of medication error risks. Mistakes included fragmented CPOE displays that prevent a clear view of patients'medications; pharmacy inventory displays mistaken for dosage guidelines; separation of functions that permit double dosing and incompatible orders; and inflexible ordering formats that generate wrong orders. The house staff (75%) reported witnessing each of the error risks, stating that they occur weekly or more often.

The researchers recommended the following ways to reduce medication errors:

  • Focus primarily on the organization of the work, not on technology
  • Aggressively examine the technology in use
  • Aggressively fix technology when it is shown to be counterproductive
  • Plan for continuous revisions and quality improvement.


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