J Clin Outcomes Manage
Computerized physician order entry, a factor in medication errors: descriptive analysis of events in the intensive care unit safety reporting system
Thompson DA, Duling L, Holzmueller CG, Dorman T, Lubomski LH, Dickman F, Fahey M, Morlock LL, Wu AW, Pronovost PJ
Abstract Objective: To describe the impact of computerized physician order entry (CPOE) on medication errors submitted to a voluntary Web-based reporting system. Setting: 18 intensive care units (ICUs) in the United States. Reporting system: The ICU Safety Reporting System (ICUSRS) is an anonymous Web-based incident reporting system developed by a team of medical and public health researchers at the Johns Hopkins University as part of a demonstration project funded by the Agency for Healthcare Research and Quality in September 2001. Results: 55 incidents were related to CPOE. The majority (85%) of CPOE incidents resulted in a medication error, while 10 events (15%) did not. Of the CPOE incidents that resulted in a medication error or near miss (an event that did not result in patient harm), 37 (67%) were coded as user errors, 11 (20%) as software errors, and 7 (13%) as computer malfunction. Conclusion: CPOE can lead to new types of errors. When implementing CPOE systems, hospital leaders should create independent checks to monitor for mistakes and ensure sufficient resources for training, be sensitive to users’ suggestions for improvement, and plan ahead regarding strategies for addressing the likely disruption in work flow and staffing.
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