Health Information Technology

Computerized prescribing may reduce some harmful medication errors, but can introduce new errors

Facilities that use computerized prescriber order entry (CPOE) reported fewer inpatient medication errors but more outpatient medication errors that reached or harmed patients than facilities without CPOE; however, the statistical significance of these differences could not be determined. Chunliu Zhan, M.D., Ph.D., of the Agency for Healthcare Research and Quality, and colleagues used a national, voluntary medication error reporting database, Medmarx, to assess the extent to which CPOE prevents medication errors. They found substantial variation across facilities in the frequency and patterns of medication errors reported and concluded that voluntary data cannot be used to compare rates of errors between providers or to determine the effectiveness of a CPOE system in reducing medication errors.

This study also examined the medication errors reportedly caused by CPOE, and analyzed the text descriptions of these errors. Facilities using Medmarx reported more than 7,000 CPOE-related medication errors over 7 months in 2003; 0.1 percent of them resulted in patient harm or adverse events. The most common CPOE errors were dosing errors (that is, wrong dose, wrong dosage form, or extra dose).

Analysis indicated that CPOE could lead to some medication errors because of faulty computer interface, miscommunication with other systems, and lack of adequate decision support. CPOE could also lead to medication errors because of common human errors such as inadequate knowledge, distractions, inexperience, and typing errors. The researchers suggest that CPOE systems should include not only optimal system design, but also features that prevent common human errors.

See "Potential benefits and problems with computerized prescriber order entry: Analysis of a voluntary medication error-reporting database," by Dr. Zhan, Rodney W. Hicks, M.S.N., M.P.A., Christopher M. Blanchette, M.A., and others, in the February 15, 2006, American Journal of Health-System Pharmacy 63, pp. 353-358. Reprints (AHRQ Publication No. 06-R056) are available from the AHRQ Publication Clearinghouse.

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