Computerized Physician Order Entry-realted Medication Errors: Analysis of Reported Errors and Vulnerability Testing of Current Systems
This is a review on Schiff, G. D., Amato, M. G., Eguale, T., Boehne, J. J., Wright, A., Koppel, R., ... & Seger, A. C. (2015) article, Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems.
Introduction & Objectives
Computerized Physician Order Entry (CPOE) has been shown to improve safety by reducing medication errors. However, CPOE also has the potential for creating errors. The objectives of this study are to look at the implications and test vulnerability of CPOE systems to reported errors.
Using the USP MEDMARX, data were collected for 1.04 billion medication error reports generated between January 2003 and April 2010. Of these reports, 63040 that were reported as CPOE-related errors were reviewed and analyzed to check for probable causes and potential prevention strategies. Error scenarios were used to test for vulnerability.
Of all the medication error reports reviewed, 6.1 percent were reported as CPOE-related. After careful analysis based on report content, reviewers found that only 5004 (49.8 percent) were actually CPOE-related errors. These error reports were classified into types and arranged by prevention codes with respect to what and why the errors occurred. Reviewers identified 338 error reports that were used for vulnerability testing of thirteen CPOE systems at sixteen sites.
The most common CPOE-related medication errors included:
1. Missing or incorrect directions/patient instructions
2. Ordered wrong dose or strength
3. Missing quantity or wrong number ordered
5. Wrong schedule entered
6. Duplicate order: same exact drug
7. Overdose or potential overdose
8. Ordered wrong formulation/dosage form
9. Order not processed/delayed
10. Extra dose potential
11. Ordered wrong drug
According to the analysis of error reports reviewed, CPOE was found to be a contributing factor to some of the medication errors. These are some of the / unintended consequences of Health Information Technology (HIT). By having an awareness of causation and conducting vulnerability testing, these errors can be mitigated. Continuous quality improvement of CPOE systems is required to reduce or completely eliminate the types of medication errors reviewed in this study.
The primary goal of CPOE systems and Health Information Technology (HIT) in general is patient safety. In this study, the medication error database was analyzed for CPOE-related errors that were found. Review and analysis of the types, causes, prevention strategies, and frequency of these errors validate the requirement of continuous quality improvement of CPOE system features that would prevent errors, including continued education and training of users.
- Schiff, G. D., Amato, M. G., Eguale, T., Boehne, J. J., Wright, A., Koppel, R., ... & Seger, A. C. (2015). Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems. http://qualitysafety.bmj.com/content/24/4/264.long