Kim et al1 demonstrated that in the practice of pediatric oncology, computerized physician order entry (CPOE) reduced improper dosing, missing cumulative doses, and incomplete nursing checklists. In contrast to these benefits, however, CPOE also resulted in a 5-fold increase in “not matching medication orders to treatment plans.” Although little detail was provided on the nature of these medication order/treatment plan “mismatches,” it implies that chemotherapy ordered through CPOE deviated more often from intended protocol therapy as compared with paper-ordered chemotherapy. While CPOE ostensibly led to more precise chemotherapy dosing, it increased the risk of that chemotherapy being the wrong chemotherapy.
Dickens D, Sinsabaugh D, Winger B. Primum Non Nocere. Arch Pediatr Adolesc Med. 2006;160(11):1185–1186. doi:10.1001/archpedi.160.11.1185-a