Perceived increase in mortality after process and policy changes implemented with computerized physician order entry
Several authors sent letters to the editor regarding the article "Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system by Han YY, Carcillo JA, et al that appeared in Pediatrics, volume 116 (6), in December of 2005.
The first letter by Longhurst C, Sharek P, et al raises concerns that the conclusions noted by Han et al were not justified by their data. They note several policy changes that occured at the time of computerized physician order entry (CPOE) that were problematic and were not required by the use of CPOE. They include the removal of antibiotics and vasoactive agents from the pediatric intensive care unit (PICU) and their placement in the pharmacy. They also note the delay in placing orders until after the patient was physically present. This is not required by CPOE but was implemented by the hospital. They also raise concerns regarding inadequate preparation for the implementation.
The second letter (Jacobs BR, Brilli RJ, Hart KW. Pediatrics. 2006 April; 117(4): 1451-1452) echos the concern about implementation strategy. They raise points about a lack of involvement by pediatric critical care physicians, use of an adult general medicine platform, poor timing of the training period, lack of order sets, and system problems that led to slow performance.
The third letter (Rosenbloom ST, Harrell FE, Lehmann CU, Schneider JH, Spooner SA, Johnson KB. Pediatrics. 2006 April; 117(4): 1452-1455) notes that morality is highly variable and is "sensitive to many factors including policy changes at the hospital, staffing ratios, and seasonal variations in disease". They also felt that problems with implementaion were more to blame than the CPOE system itself.
All of these letters to the editor emphasize that CPOE can not eliminate all errors by itself. This issue is also highlighted in another recent article (Walsh KE, Adams WG, et al. Medication Errors Related to Computerized Order Entry for Children. Pediatrics. 2006 November; 118(5): 1872-1879). These authors note that "of all pediatric medication errors detected, 19% (7 serious and 13 with little potential for harm) were computer related". Ongoing study of computer related errors is critical to the development of better systems that can truly lead to a substantial reduction/near elimination of medication errors.