Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors

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This is a review of the study entitled. Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors. [1]


This article touches bases on how CPOE plays an enormous role in facilitating medication errors. It also focuses on the types and existence of medication errors


Qualitative and Quantitative study among house staff at a tertiary-care teaching hospital. The methods used were one-on-one Interviews, Focus Group, Expert Interviews, Shadowing and Observation.

  • House staff
  • Information technology leaders
  • Pharmacy leaders
  • Attending physicians
  • Nurses
    • Participants were paid $40, group size 7-18 hours spent 1.4-2


22 types of medication errors risk were founds, for example

  • Fragmented CPOE displays that prevent a coherent view of patients medication
  • Pharmacy inventory displays mistaken for dosage guidelines
  • Ignored antibiotic renewal notices
  • Double dosing and incompatible orders
  • Inflexible ordering generating wrong orders.

These 22 medication errors were grouped into two categories: Information Errors and Human-Machine Interface Flaws. Out of the clinical staff 94 interns were contacted and out of the 94, 85 participated.


Although a perceived benefit of CPOE systems is prevention of adverse drug events, the systems may facilitate new and unexpected medication errors by users. Careful attention should be paid to the development of these errors after system implementation.

Advantages of CPOE Systems Compared to paper-based systems

  • Handwriting free errors
  • Faster responds time to pharmacy
  • Less error with similar Drug Names
  • Linking to ADE reporting easier
  • Reduces incorrect drug choices
  • Reduces underprescribing and overprescribing


  1. Ross Koppel, PhD; Joshua P. Metlay, MD, PhD; Abigail Cohen, PhD; Brian Abaluck, BS; A. Russell Localio, JD, MPH, MS; Stephen E. Kimmel, MD, MSCE; Brian L. Strom, MD, MPH. JAMA. 2005;293(10):1197-1203. doi:10.1001/jama.293.10.1197. Retrieved from