Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems

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  • IMPORTANCE:Medication computerised provider order entry (CPOE) has been shown to decrease errors and is being widely adopted. However, CPOE also has potential for introducing or contributing to errors.
  • OBJECTIVES:The objectives of this study are to (a) analyse medication error reports where CPOE was reported as a 'contributing cause' and (b) develop 'use cases' based on these reports to test vulnerability of current CPOE systems to these errors.
  • METHODS:A review of medication errors reported to United States Pharmacopeia MEDMARX reporting system was made, and a taxonomy was developed for CPOE-related errors. For each error we evaluated what went wrong and why and identified potential prevention strategies and recurring error scenarios. These scenarios were then used to test vulnerability of leading CPOE systems, asking typical users to enter these erroneous orders to assess the degree to which these problematic orders could be entered.
  • RESULTS:Between 2003 and 2010, 1.04 million medication errors were reported to MEDMARX, of which 63 040 were reported as CPOE related. A review of 10 060 CPOE-related cases was used to derive 101 codes describing what went wrong, 67 codes describing reasons why errors occurred, 73 codes describing potential prevention strategies and 21 codes describing recurring error scenarios. Ability to enter these erroneous order scenarios was tested on 13 CPOE systems at 16 sites. Overall, 298 (79.5%) of the erroneous orders were able to be entered including 100 (28.0%) being 'easily' placed, another 101 (28.3%) with only minor workarounds and no warnings.
  • CONCLUSIONS AND RELEVANCE:Medication error reports provide valuable information for understanding CPOE-related errors. Reports were useful for developing taxonomy and identifying recurring errors to which current CPOE systems are vulnerable. Enhanced monitoring, reporting and testing of CPOE systems are important to improve CPOE safety.




Once thought to be a highly error resistant, Computerised Provider Order Entry (CPOE) has begun to have documented errors that have not been seen before. Due to these errors, the FDASIA recommended developing approaches for error compilation. SInce 2003, when the USP error recording system was able to record CPOE errors, it has become the third leading cause of errors being submitted.It is the goal of this article to analyze data from 10,000 of these CPOE reported errors and assess vulnerabilities of leading CPOE systems.


Phase 1

THe MEDMARX system was searched for CPOE errors from Jan 2003 to Apr 2010. 63,040 queries were collected from a total of 1.04 million reports. These reports were then reviewed and coded according to the National Coordination Council for Medication Error Reporting and Prevention.

Phase 2

A weighted scoring system was used based on error frequency, severity, generalisability, and testability. Based on these scores 21 test scenarios were choosen. The scenarios were then tested on test patients at a sample of leading vendor and homegrown CPOE systems, and the ease at which these orders were entered was recorded.


Phase 1

Of the reported errors 6.1% were caused by CPOE systems. Though of these reports the reviewers could only determine 49.8% were caused by CPOE systems with what was written in the report.

Phase 2

338 error reports were identified as potential test scenarios, but the list was narrowed to 21 using the criteria presented before. The test scenarios were tested on 13 representaive systems at 16 different test sites. Overall, 79.5% of the errors were able to be placed with 56.3% of those being easily placed, though the rest required only a few workarounds. 26.6% of the orders produced warnings, with 69% being passive and the others requiring workarounds.


The report gives great detail into the types of errors that occur in CPOE systems, with about 56.3% of the 6% of errors occuring easily in 13 different systems. Though many of the problems are not unique to CPOEs and in fact occur in written orders as well. A problem seen is that warnings have been so toned down as to not interupt the physcians that they have in fact been causing other problems. An shockingly in one of the systems the warning had been turned off for an upgrade months prior and had not been reinstated until these tests were done. And while this report was based on self-reporting it shows that there is a need to improve the current CPOE systems as well as the need for a more standardized reporting system.


I think overall this is a very good paper, and the results would suprise most people that read it. I find that CPOE systems being in the top three error causers for medications to be crazy, and the fact that systems can have their warning turned off for months on end and still work blows my mind. This technology is here to help physicians, but when we start to rely to much on technology there is still the chances that errors will occur and that we wont even know that they are happening.

I think your article encompasses what we are afraid to confront in HIT, medical errors. If the order is sent incorrectly there is a slight chance the pharmacist might catch on it. However, the CDS alerts and notifications may be able to reduce the CPOE errors. Overall, the EHR system continues to be a great challenge in order to provide safety, privacy and the ability to reduce medical errors.


  1. Schiff 2015