Public Release: 

Computerized order entry systems can increase risk of medication errors

The JAMA Network Journals

A new study suggests that computerized order entry systems which are implemented in part to reduce prescribing errors can actually increase the risk of medication errors in certain situations, according to a study in the March 9 issue of JAMA.

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 orders, and inflexible ordering formats generating wrong orders. Three-quarters of the house staff reported observing each of these errors risks, indicating that they occur weekly or more often. Use of multiple qualitative and survey methods identified and quantified error risks not previously considered, offering many opportunities for error reduction.

"The literature on CPOE, with few exceptions, is enthusiastic. Our findings, however, reveal that CPOE systems can facilitate error risks in addition to reducing them. Without studies of the advantages and disadvantages of CPOE systems, researchers are looking at only one edge of the sword. This limitation is especially noteworthy because many problems we identified are easily corrected," the authors write.

The researchers make several recommendations on how to reduce medication errors. "(1) Focus primarily on the organization of work; not on technology; CPOE must determine clinical actions only if they improve, or at least do not deteriorate, patient care. (2) Aggressively examine the technology in use; problems are obscured by workarounds, the medical problem-solving ethos, and low house staff status. (3) Aggressively fix technology when it is shown to be counterproductive because failure to do so engenders alienation and dangerous workarounds in addition to persistent errors; substitution of technology for people is a misunderstanding of both. (4) Pursue errors' 'second stories' and multiple causations to surmount the following barriers enhanced by episodic and incomplete error reporting, which is standard, and management belief in these reports, which obfuscates and compounds problems. (5) Plan for continuous revisions and quality improvement, recognizing that all changes generate new error risks," the researchers write.

"As CPOE systems are implemented, clinicians and hospitals must attend to the errors they cause, in addition to the errors they prevent."

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(JAMA. 2005;293:1197-1203. Available post-embargo at JAMA.com)

Editor's Note: This research was supported by a grant from the Agency for Healthcare Research and Quality, Improving Patient Safety Through Reduction in Medication Errors. Co-author Dr. Metlay is also supported through an Advanced Research Career Development Award from the Health Services Research and Development Service of the Department of Veterans Affairs.

Editorial: Computer Technology and Clinical Work

In an accompanying editorial, Robert L. Wears, M.D., M.S., of the University of Florida, Jacksonville, and Marc Berg, M.A., M.D., Ph.D., of Erasmus University, Rotterdam, the Netherlands, discuss the findings by Koppel et al and a review article in this issue by Garg et al which examined computerized clinical decision support systems.

"These results are disappointing but should not be surprising. There is a long-standing, rich, and abundant literature on the problems associated with the introduction of computer technology into complex work in other domains, as well as occasional notes in health care. Clearly, there is no reason to expect health care, which is from an organizational standpoint probably the most complex enterprise in modern society, to be immune to them. Taken together, these 2 studies suggest that important lessons about introducing new technologies into complex work seem to have been missed."

"For a small but important example, it has been long established in software engineering that systems cannot be adequately evaluated by their developers, a principle that seems to be commonly overlooked in health care. Since roughly 75 percent of all large IT projects in health care fail, inattention to these lessons is, at best, wasteful of time and resources and, at worst, harmful to patients and clinicians.

"To begin to move forward, it is necessary to dispense with the commonly held notion that these problems are simply bits of bad programming or poor implementation that can easily be excised or avoided the next time around," the authors write. "In short, rather than framing the problem as 'not developing the systems right,' these failures demonstrate 'not developing the right systems' due to widespread but misleading theories about both technology and clinical work."

"... an information technology in and of itself cannot do anything, and when the patterns of its use are not tailored to the workers and their environment to yield high-quality care, the technological interventions will not be productive. This implies that any IT acquisition or implementation trajectory should, first and foremost, be an organizational change trajectory. This is true at both the organizational level and the national level; a national health IT infrastructure without a clear logic about how health care organizations will become engaged in this infrastructure is bound to fail," the authors write.

(JAMA. 2005;293:1261-1263. Available post-embargo at JAMA.com)

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