Computerized Provider Order Entry and Patient Safety

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Key Points

  • Pediatric patients are particularly vulnerable to prescribing errors.

  • Research on the impact of CPOE systems for pediatric patients is growing.

  • CPOE has tremendous potential for improving patient safety but can also have unintended consequences.

  • Much of the research on the effectiveness of CPOE among pediatric patients has been on reduction in prescribing errors.

  • Future research should focus on the effectiveness of CPOE with CDS on actual outcomes for pediatric patients, and other workflow and

Definitions

CPOE refers to a provider's use of computer assistance to directly enter medical orders, such as medications, consultations with other providers, laboratory services, imaging studies, and other auxiliary services. CPOE is often used to describe this process in the inpatient setting. Electronic transmission of prescriptions directly to pharmacies (ePrescribing) is commonly an associated functionality.

Much of the value of CPOE is believed to come from clinical decision support (CDS). CDS refers

Medication errors

Medication errors can occur at any step in the medication process (defined by the Institute of Medicine as prescribing, transcribing, dispensing, administering, and monitoring a medication).1 CPOE largely targets prescribing errors. Common types of prescribing errors include incorrect dosing (overdosing and underdosing); incorrect drug selection; incorrect frequency; wrong patient; incorrect route of administration; and illegibility (for handwritten orders). Near misses are a type of error with

The epidemiology of pediatric medication errors

Research on the epidemiology of pediatric medication errors suggests these errors occur with great frequency. In the inpatient setting, a study conducted by Kaushal and colleagues3 found that 5.7% of handwritten inpatient orders contained prescribing errors with low potential for harm; 1.1% contained near misses; and 0.24% resulted in ADEs, of which 19% were preventable. Importantly, the rate of near misses was triple that compared with adults.7 Most errors occurred at the prescribing stage and

The unique vulnerability of children to medication errors

Children seem to be particularly vulnerable to medication errors and ADEs for a variety of reasons (Box 1).1, 2, 3 Some factors are intrinsic to the nature of being a child, whereas others are related to how medications are ordered and used among pediatric patients.

Proposed benefits of CPOE

Given the scope of the problem facing pediatric patients, HIT is increasingly being promoted and used as a way to improve patient safety. Indeed, use of CPOE is one of the core requirements providers must demonstrate to be eligible for financial incentives through the electronic health record (EHR) incentive program, an unprecedented federal initiative promoting adoption and meaningful use of EHRs.4 The emphasis being placed on use of CPOE stems from the many potential benefits of CPOE use.

Impact of CPOE systems on patient safety

In the inpatient and outpatient setting, multiple studies have shown that CPOE can reduce the frequency of medication errors for adult patients.24, 25, 26, 27, 28 For example, a study conducted by Bates and colleagues25 evaluating medication errors among adult inpatients found that CPOE eliminated more than 80% of nonmissed drug medication errors. In the outpatient setting, a recent study of community-based ambulatory care adult providers found that introduction of electronic order entry

Unintended consequences of CPOE

Although CPOE has tremendous promise, there are also important pitfalls. Several studies have evaluated unintended consequences after CPOE implementation. Unintended consequence is the term often used to describe a consequence that is unanticipated and undesirable.

One important type of unintended consequence of CPOE implementation is the fostering of new types of errors.38, 39, 40, 41, 42 One such error is a juxtaposition error, in which the clinician inadvertently chooses the incorrect patient

Policy implications and future directions

For many years, rates of CPOE adoption and use by hospitals and ambulatory providers were extremely low. However, these rates have been steadily increasing, and are expected to continue to increase dramatically in light of the federal incentives provided through the EHR incentive program. As of 2010, an estimated 21.7% of US hospitals had CPOE, compared with only 15.7% in 2009.47 Among eligible ambulatory providers, 390,000 prescribed electronically (58% of all office-based prescribers). This

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