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Computerized physician order entry prevents drug errors, but can initially result in new errors in ICUs

Computerized physician order entry (CPOE) systems typically prompt users who are entering medication orders about dosage recommendations, drug interaction warnings, and patient allergies. In the long run, CPOE systems are likely to prevent some types of medication errors. Nevertheless, when systems are first implemented, the risk for a medication error may increase in intensive care units (ICUs), suggests a study supported by the Agency for Healthcare Research and Quality (HS11902).

Researchers found that 55 CPOE-related incidents were reported to the voluntary Web-based Intensive Care Unit Safety Reporting System (ICUSRS) by 18 ICUs between July 1, 2002 and June 20, 2003. Overall, 85 percent of CPOE incidents resulted in medication errors, while 15 percent did not. Of the CPOE incidents that resulted in a medication error or a near miss (an event that did not result in patient harm), 67 percent were coded as user errors, 20 percent as software errors, and 13 percent as computer malfunction problems. Lack of training and education was a contributing factor in 43 percent of the 55 CPOE incidents, team factors (for example, not communicating an order to change a medication dose to the nurse) accounted for 20 percent of CPOE incidents, and provider factors, such as fatigue, accounted for 16 percent. The majority (88 to 98 percent) of CPOE events reported did not result in patient harm.

Implementing a CPOE system creates new risks and types of errors, caution Johns Hopkins University researchers. For example, selection errors may replace transcription errors. When scrolling down the medication list on the computer screen, it is easy to select the wrong dose or incorrect medication. They suggest that when implementing CPOE systems, ICUs should include independent checks to monitor for mistakes, ensure there are sufficient resources for training, and plan ahead to address the likely disruption in work flow and staffing when implementing a new CPOE system.

More details are in "Computerized physician order entry, a factor in medication errors: Descriptive analysis of events in the intensive care unit safety reporting system," by David A. Thompson, D.N.Sc., M.S., R.N., Laura Duling, Christine G. Holzmueller, B.L.A., and others, in the August 2005 Journal of Clinical Outcomes Management 12(8), pp. 407-412.

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