Medication errors possible due to flaws in CPOE use

According to a study of hospital clinicians’ experience, supported by the Agency for Healthcare Research and Quality (AHRQ) and published in a recent issue of the Journal of the American Medical Association (JAMA), systems must be implemented thoughtfully to avoid facilitating certain types of errors in computerized physician order entry (CPOE).

The study, led by Ross Koppel, PhD, of the University of Pennsylvania’s Department of Sociology, was based on interviews with medical staff, focus groups, shadowing staff as they worked, and a survey of interns and residents at a major urban teaching hospital with a widely used CPOE system.

Pointing out that ideally “principles of human factors research, usability testing, and workflow impact should all be considered before products are released into the workplace,” AHRQ Director Carolyn M. Clancy, MD, said the findings, which are “typical for products early in their implementation,”  were valuable to the AHRQ. The agency is funding more than $139 million in grants and contracts nationwide over three years to support planning, implementation and evaluation of health information technologies, including CPOE.

The study, “Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors,” identified 22 situations in which the CPOE system increased the probability of medication errors.

Some flaws identified by the study included:

>> Medical staff may look to the CPOE system to determine minimal effective or usual dosage for infrequently used medications. However, the CPOE system may only reflect dosage sizes available at the pharmacy, which may differ from the minimal or usual dosage that should be prescribed. The flaw represents an inappropriate use of the data available on the CPOE system and could result in prescribing incorrect dosage.

>> Clinicians might select the wrong patient file because names and drugs can be hard to read, computer mice are often imprecise, and patients’ names do not appear on all screens.

>> A patient’s medication information is seldom synthesized on a single screen. Up to 20 screens might be needed to see all of a patient’s medications, increasing the likelihood of selecting a wrong medication.

>> Because of the patient load and multiple tasks, nurses are often unable to enter timely information on the computer about the administration of drugs. The delayed information may affect later medication and clinical decisions.

>> Computer downtime, whether for maintenance or in the event of “crashes,” can result in delays in medications reaching patients.

Dr. Clancy said this study “shows the need for early testing of products by both product designers and purchasers, as well as ongoing refinement and improvement in the products themselves as medical and other staff interact with them.”

SOURCE: “Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors.” 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;293:1197-1203.