Adverse drug events (ADEs) are estimated to injure or kill more than 770,000 patients in hospitals annually, according to background information on the article. Prescribing errors are the largest identified source of preventable hospital medical error. Computerized physician order entry (CPOE) systems are widely viewed as crucial for reducing prescribing errors and potentially saving hundreds of billions in annual costs. Published studies have indicated that CPOE reduces medication errors up to 81 percent. Few researchers, however, have focused on the existence or types of medication errors facilitated by CPOE.
Ross Koppel, Ph.D., of the University of Pennsylvania School of Medicine, Philadelphia, and colleagues conducted a study of CPOE-related factors that enhance risk of prescription errors. The researchers performed a qualitative and quantitative study of house staff interaction with a CPOE system at a teaching hospital. They surveyed house staff (N = 261; 88 percent of CPOE users); conducted 5 focus groups and 32 intensive one-on-one interviews with house staff, information technology leaders, pharmacy leaders, attending physicians, and nurses; shadowed house staff and nurses; and observed them using CPOE. Participants included house staff, nurses, and hospital leaders .
The researchers found that the CPOE system they studied facilitated 22 types of medication error risks. Examples include fragmented CPOE displays that prevent a coherent view of patients' medications, pharmacy inventory displays mistaken for dosage guidelines, ignored antibiotic renewal notices placed on paper charts rather than in the CPOE system, separation of functions that facilitate double dosing and incompatible ord
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