The vulnerabilities of computerized physician order entry systems: a qualitative stud
- To test the vulnerabilities of various currently used computerized physician order entry systems (CPOEs) to different types of medical errors.
- To collect essential information for qualitative analysis that can help understand effective tactics and improve design and usability of CPOEs.
The following is a summary of all methods used in this investigation .
- Reviewed a random sample of 63040 medical error reports from the US Pharmacopeia (USP) MEDMARX reporting system.
- CPOE-contributed errors.
- Capable to be tested in current CPOE systems.
- To identify interface design, usability and workflow related issues.
- CPOE systems often failed to detect and prevent important medical errors.
- Variations of the means of alert generation.
- High frequency of confused alerts.
- Unrelated warning display with current erroneous entry.
- Delayed warnings for dangerous drug-drug interactions that did not display at the time of order entry.
- Lack of clinical decision support (CDS) protections.
- Unclear wording for warnings in some CPOEs.
- High variability among different CPOE systems.
- Healthcare organizations are probably not getting all the safety benefits that they presumably should have by using CPOE plus CDS.
- To change this scenario, design and implementation of an appropriately designed a CDS system to improve effectiveness and usability of current CPOE systems could be one of effective tactics. In addition, human factors need to be carefully considered in this hybrid system.
- Slight, S. P., Eguale, T., Amato, M. G., Seger, A. C., Whitney, D. L., Bates, D. W., & Schiff, G. D. (2015). The vulnerabilities of computerized physician order entry systems: a qualitative study. Journal of the American Medical Informatics Association: JAMIA. http://doi.org/10.1093/jamia/ocv135