A 75-year-old man was admitted on a Tuesday evening with abdominal pain, jaundice, and elevated liver function tests, including a bilirubin of 10.3 mg/dL. His CT scan demonstrated clear signs of acute cholangitis (an infection in the biliary tree, in this case due to blockage by gall stones). An order for IV antibiotics every 6 hours was placed electronically at 8:00 PM, and arrangements were made for an endoscopic retrograde cholangiopancreatography the following day to relieve the obstruction. On Wednesday morning rounds, the attending physician learned that the patient had not yet received any doses of antibiotic.
Subsequent analysis of the delay found the following: When an order is entered in the computerized provider order entry (CPOE) system, the computer assigns it a "next logical time for administration." In this case, the order placed at 8:00 PM on Tuesday was assigned a "next logical administration time" of Wednesday at 00:00. The pharmacist, uncomfortable with a 4-hour delay, manually overrode midnight and entered "9:00 PM," but the computer converted that to 9:00 PM on Wednesday, a change he did not notice. Nurses from two shifts—the night shift on Tuesday and the day shift on Wednesday—cared for this seriously ill patient, and none questioned why he wasn't receiving antibiotics or why the antibiotics were not scheduled to be given until 24 hours after admission.
1. Kohn L, Corrigan J, Donaldson M, eds. To Err Is Human: Building a Safer Health System. Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine. National Academies Press; 1999. ISBN: 9780309068376.
2. Bates DW, Cullen DJ, Laird N, et al. ADE Prevention Study Group. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA. 1995;274:29-34. [go to PubMed]
3. Lewis PJ, Dornan T, Taylor D, Tully MP, Wass V, Ashcroft DM. Prevalence, incidence, and nature of prescribing errors in hospital inpatients: a systematic review. Drug Saf. 2009;32:379-389. [go to PubMed]
4. Reckmann MH, Westbrook JI, Koh Y, Lo C, Day RO. Does computerized provider order entry reduce prescribing errors for hospital inpatients? A systematic review. J Am Med Inform Assoc. 2009;16:613-623. [go to PubMed]
5. Harrington L, Kennerly D, Johnson C. Safety issues related to the electronic medical record (EMR): synthesis of the literature from the last decade, 2000-2009. J Healthc Manag. 2011;56:31-43. [go to PubMed]
6. Niazkhani Z, Pirnejad H, van der Sijs H, Aarts J. Evaluating the medication process in the context of CPOE use: the significance of working around the system. Int J Med Inform. 2011;80:490-506. [go to PubMed]
7. van der Sijs H, Aarts J, Vulto A, Berg M. Overriding of drug safety alerts in computerized physician order entry. J Am Med Inform Assoc. 2006;13:138-147. [go to PubMed]
8. Campbell EM, Sittig DF, Guappone KP, Dykstra RH, Ash JS. Overdependence on technology: an unintended adverse consequence of computerized provider order entry. AMIA Annu Symp Proc. 2007;11:94-98. [go to PubMed]
9. Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH. Types of unintended consequences related to computerized physician order entry. J Am Med Inform Assoc. 2006;13:547-556. [go to PubMed]