Computerised Medication Systems May Cause Errors -- MEDICA - World Forum for Medicine

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.

Computerised 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.

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.

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 and ignored antibiotic renewal notices placed on paper charts rather than in the CPOE system.

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.; Source: American Medical Association (AMA)