Med ordering errors linked to CPOE use

Doc and computer

Computerized physician order entry can reduce medical error rates, but also can also facilitate new types of errors, according to new research published in the Journal of the American Medical Informatics Association (JAMIA).

For the study--with contributors from Atrius Health, Brigham and Women’s Hospital, Columbia University Medical Center, Kaiser Permanente Northwest, Partners HealthCare, the University of Illinois at Chicago and the University of Pennsylvania--researchers reviewed all patient medication error reports from six sites participating in a Food and Drug Administration-sponsored project examining CPOE safety.

Of 2,522 reports of errors in the medication ordering phase, more than half (51.9 percent) were related to CPOE. Of these, CPOE facilitated the error in 13.1 percent and potentially could have prevented the error in 86.9 percent. Mistakes facilitated by CPOE included erroneous names in the system for drug formularies, problems entering the order leading to a workaround, outdated order sets, protocols and dictionaries, and pull down menu problems. Errors where CPOE could have prevented an error but failed to do so included inadequate clinical decision support alerts, lack of electronic communication of discontinuation of a CPOE order to the pharmacy and medication reconciliation errors.

The most frequent categories of "what happened to the patient," according to the study, were delays in medications reaching the patient, potentially receiving duplicate drugs, or receiving a higher dosage than indicated. The most frequent categories for "what happened in CPOE’" included orders not routed to the intended location, wrong dose ordered and duplicate orders. Still, the researchers could determine why an error occurred in only 30.8 percent of the cases, since the error reports were not sufficiently detailed.

The study recommended, among other things, better system design, more effective alerts, improved interoperability, and default dosing and/or access to drug information about usual doses incorporated when necessary.

“Such adverse event information should be made more accessible within and across systems in order to systematically learn from past errors and issues and provide feedback to institutions and commercial vendors to assist in improving CPOE design and usability,” the researchers said.