Comprehensive Analysis of a Medication Dosing Error Related to CPOE

This is a systematic review of the article entitled “Comprehensive Analysis of a Medication Dosing Error Related to CPOE” by Jan Horsky .

Introdution

New drugs that manage or relieve previously untreated diseases have come about due to new innovations in pharmacology research. These advancements in drug therapy have led to increased incidence of Adverse drug event (ADEs) due to avoidable causes such as prescribing errors. Computerized physician order entry (CPOE) systems are known to drastically minimize the incidence of ADEs by confirming legibility of orders and integrating clinical decision support (CDS) such as checking for allergies.

However, the progressive effect of CPOE on prescribing safety can be compromised by the advent of new forms of errors. These errors are related to the intricacy of the human-computer interaction and may be a consequence of poor user training or inadequate understanding of data handling by a CPOE application.

Understanding the acuity of users at crucial stages of an incident that occurred during the use of CPOE is extremely beneficial to the process of characterizing cognitively based errors. In this article, the case of a serious medication error that occurred at a large academic medical institution is described and a synopsis of how the error was analyzed is discussed. The authors hope that characterization of the entire process of the error will provide key insight and recommendations for improving CPOE systems and clinical ordering procedures.