Flaws in Use of Computerized Order Entry Could Lead to Errors

While computerized physician order entry (CPOE) is expected to significantly reduce medication errors, systems must be implemented thoughtfully to avoid facilitating certain types of errors, according to a study supported by the Agency for Healthcare Research and Quality (AHRQ) and published in the March 9 issue of the Journal of the American Medical Association. The study looks at clinicians experience in using one CPOE system at a major urban teaching hospital.


AHRQ Director Carolyn M. Clancy, MD, said the findings are typical for products early in their implementation. New health care information technology products usually go through an ongoing process of refinement and improvement as health care workers identify problems, she said. Ideally, principles of human factors research, usability testing, and workflow impact should all be considered before products are released into the workplace.


While the findings are important, the study focuses on the experience of one hospital and one product and may not be easily applied to industry at large, Clancy said. It means these products are in their early implementation period, and there will be a learning period to improve both these systems and make CPOE function at its best. She said implementation problems would be minimized through testing before products are marketed, and through adaptation to meet the needs of individual clinical settings.


The use of health information technology to reduce medical errors and improve patient safety has been extensively documented and supported in peer-reviewed literature. Last year, President Bush called for the widespread adoption and use of electronic medical records within the next 10 years and established the Office of the National Coordinator for Health Information Technology.


"The findings from this study show that the particular way that computerized physician order entry products are developed and implemented makes all the difference in whether quality is improved," said David Brailer, MD, PhD, national coordinator for health information technology. "This study emphasizes the important need for health information technology products to talk to one another so that patient information can be shared."


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. According to the study, these situations fell into two categories: information errors generated by fragmentation of data and hospitals many information systems; and interface problems between humans and machines, where the computers requirements are different than the way clinical work is organized.


Some of the flaws identified by the study include:


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 patients medication information is seldom synthesized on a single screen. Up to 20 screens might be needed to see all of a patients 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.


The study was led by Ross Koppel, PhD, of the University of Pennsylvania. It is 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.


Clancy said AHRQ found the findings valuable. AHRQ 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. AHRQ is also funding studies of how information technologies affect clinical workflow. AHRQ-supported projects assess the benefits and also identify any problems in using health information technology.


This study represents a step forward in the ongoing process of integrating health information technology products into our healthcare settings and ensuring that the products are well-designed and readily promote proper use in improving quality of care, Clancy said. It also 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.


In addition, AHRQ is working with an organization of leading employers who are major health benefits purchasers, the Leapfrog Group, to develop an evaluation tool to assess the effectiveness of CPOE and electronic prescribing in reducing medical errors. The development of this evaluation tool is being supported to encourage and enable ongoing evaluation of CPOE and other information technologies as they are considered for incorporation into clinical settings to improve the quality of healthcare.


Source: Agency for Healthcare Research and Quality (AHRQ)