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We are writing in response to Abraham et al.’s recent review of systematic reviews (SR) targeting the impact of computerised provider order entry (CPOE) on clinical and safety outcomes . We commend the authors’ inclusion of medication errors and adverse drug events (ADE) among the outcomes assessed. This is particularly timely given the World Health Organisation’s 2017 announcement of the third Global Patient Safety Challenge to motivate actions to reduce medication errors causing actual patient harm by half in five years . Abraham et al. concluded that, based on the evidence reported by three SR of inpatient populations, pooled studies showed significant reduction in ADEs with CPOE use, with considerable variation in the magnitude of relative risk reduction . However, there are significant limitations to the studies on which this conclusion is based, and we believe a more cautious approach should be taken when assessing the current evidence.
Firstly, as the authors acknowledged, there was variation in the definitions of ADE across the three SR and the 18 studies they included. We agree that these are significant limitations when trying to summarise the impact of CPOE on ADE. To be clear, the included studies assessed preventable ADEs (10 studies) and/or potential ADEs (15 studies), and three studies did not specify the type of ADE. An ADE can be preventable, non-preventable, or potential . A preventable ADE refers to a medication error which reached th...
Firstly, as the authors acknowledged, there was variation in the definitions of ADE across the three SR and the 18 studies they included. We agree that these are significant limitations when trying to summarise the impact of CPOE on ADE. To be clear, the included studies assessed preventable ADEs (10 studies) and/or potential ADEs (15 studies), and three studies did not specify the type of ADE. An ADE can be preventable, non-preventable, or potential . A preventable ADE refers to a medication error which reached the patient and resulted in actual patient harm. A non-preventable ADE, or adverse drug reaction, is defined as harm resulting from an unexpected reaction to a drug where there was no medication error. A potential ADE, or near-miss, is typically defined as a medication error with the potential for harm but in which no harm occurred due to patient circumstance or an intervention . In the wider medication safety literature, many studies which assess ADEs do not delineate whether this harm was, the much more frequently occurring, potential harm or the relatively rare actual harm .
Further limitations of the studies of ADEs and CPOEs not discussed were the data collection methods. There is significant variation in the methods undertaken by the included studies to identify ADEs. Firstly, there were eight studies using voluntary incident reports as the only source for identifying ADEs. Incident reports are known to result in significant under-estimation of errors and ADEs . Eight studies used the more rigorous chart and record review. Finally, the study designs do not allow for drawing causal conclusions. That is, there were no randomised controlled trials. Except for one cohort study, all the studies used before-after designs, only one of which included a control.
In conclusion, only half the studies (n=10) included assessed the impact of CPOE on actual patient harm resulting from a medication error. Of these studies, only three reported a significant reduction in patient harm, with the most recent data collection completed in 2010. Five studies reported no significant effect and two studies reported an increase. Of the six studies identifying preventable ADE by chart review, three studies reported a significant reduction (a pooled total of 157 events compared to 139 events) and three studies reported no significant effect.
Considering the very significant limitations across studies, we believe there is not yet convincing evidence of the direct impact of CPOE on actual patient harm. This conclusion remains consistent with two earlier umbrella reviews [6, 7].
1. Abraham, J., et al., Effects of CPOE-based medication ordering on outcomes: an overview of systematic reviews. BMJ Quality &amp; Safety, 2020: p. bmjqs-2019-010436.
2. Donaldson, L.J., et al., Medication without harm: WHO's Third Global Patient Safety Challenge. The Lancet, 2017. 389(10080): p. 1680-1681.
3. Bates, D.W., et al., Relationship between medication errors and adverse drug events. J Gen Intern Med, 1995. 10(4): p. 199-205.
4. Gates, P.J., et al., Standardising the Classification of Harm Associated with Medication Errors: The Harm Associated with Medication Error Classification (HAMEC). Drug Safety, 2019. 42(8): p. 931-939.
5. Westbrook, J.I., et al., What are incident reports telling us? A comparative study at two Australian hospitals of medication errors identified at audit, detected by staff and reported to an incident system. Int J Qual Health Care, 2015. 27(1): p. 1-9.
6. Ranji, S.R., S. Rennke, and R.M. Wachter, Computerised provider order entry combined with clinical decision support systems to improve medication safety: a narrative review. BMJ Qual Saf, 2014. 23(9): p. 773-80.
7. Weir, C.R., N. Staggers, and T. Laukert, Reviewing the impact of computerized provider order entry on clinical outcomes: The quality of systematic reviews. International Journal of Medical Informatics, 2012. 81(4): p. 219-231.