Customize your JAMA Network experience by selecting one or more topics from the list below.
Koppel R, Metlay JP, Cohen A, et al. Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors. JAMA. 2005;293(10):1197–1203. doi:10.1001/jama.293.10.1197
Author Affiliations: Department of Sociology
(Dr Koppel), Department of Medicine, Cardiovascular Division (Dr Kimmel) and
General Medicine Division (Drs Metlay and Strom), Center for Clinical Epidemiology
and Biostatistics (Drs Koppel, Metlay, Cohen, Kimmel, and Strom and Mr Localio),
Department of Biostatistics and Epidemiology (Drs Metlay, Kimmel, and Strom
and Mr Localio), Department of Pharmacology (Dr Strom), Center for Education
and Research in Therapeutics (Drs Metlay and Strom and Mr Localio), University
of Pennsylvania School of Medicine (Mr Abaluck), Philadelphia; and Center
for Health Equity Research and Promotion, Department of Veterans Affairs,
Philadelphia (Dr Metlay).
Context Hospital computerized physician order entry (CPOE) systems are widely
regarded as the technical solution to medication ordering errors, the largest
identified source of preventable hospital medical error. Published studies
report that CPOE reduces medication errors up to 81%. Few researchers, however,
have focused on the existence or types of medication errors facilitated by
Objective To identify and quantify the role of CPOE in facilitating prescription
Design, Setting, and Participants We performed a qualitative and quantitative study of house staff interaction
with a CPOE system at a tertiary-care teaching hospital (2002-2004). We surveyed
house staff (N = 261; 88% 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.
Main Outcome Measure Examples of medication errors caused or exacerbated by the CPOE system.
Results We found that a widely used CPOE system 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 error 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.
Conclusions In this study, we found that a leading CPOE system often facilitated
medication error risks, with many reported to occur frequently. As CPOE systems
are implemented, clinicians and hospitals must attend to errors that these
systems cause in addition to errors that they prevent.
Create a personal account or sign in to: