Computerized physician order entry systems can introduce new types of medication error

It’s well documented that computerized physician order entry systems (CPOE) reduce medication errors in the hospital. However, the March 9 issue of the Journal of the American Medical Association (JAMA) reports 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.

Technology is a tool to improve safety, quality, and efficiency, but it’s not a panacea. Good system design and implementation is as critical and difficult in medicine as in any other sector. IT systems usually fail to deliver on their promise at first, and sometimes cause new problems. It takes a while to produce substantial improvements, so hospitals should get started now to gain experience and learn from their mistakes.

March 8, 2005

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