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CHUNLIU ZHAN, M.D., PH.D., is Senior Service Fellow, Agency for Healthcare Research and Quality (AHRQ), Rockville, MD. RODNEY W. HICKS, M.S.N., M.P.A., is Research Coordinator, Center for the Advancement of Patient Safety, United States Pharmacopeia (USP), Rockville. CHRISTOPHER M. BLANCHETTE, M.A., is Research Associate, School of Pharmacy, University of Maryland, Baltimore. MARGARET A. KEYES, M.A., is Patient Safety Team Leader, AHRQ. DIANE D. COUSINS is Vice President, Center for the Advancement of Patient Safety, USP.
Address correspondence to Dr. Zhan at the Agency for Healthcare Research and Quality, Rockville, MD 20850 (czhan{at}ahrq.gov).
Methods. A national voluntary medication error-reporting database, Medmarx, was used to compare facilities that had CPOE with those that did not have CPOE. The characteristics of medication errors reportedly caused by CPOE were explored, and the text descriptions of these errors were qualitatively analyzed.
Results. Facilities with CPOE reported fewer inpatient medication errors and more outpatient medication errors than facilities without CPOE, but the statistical significance of these differences could not be determined. Facilities with CPOE less frequently reported medication errors that reached patients (p < 0.01) or harmed patients (p < 0.01). More than 7000 CPOE-related medication errors were reported over seven months in 2003, and about 0.1% of them resulted in harm or adverse events. The most common CPOE errors were dosing errors (i.e., wrong dose, wrong dosage form, or extra dose). Both quantitative and qualitative analyses indicate that CPOE could lead to medication errors not only because of faulty computer interface, mis-communication with other systems, and lack of adequate decision support but also because of common human errors such as knowledge deficit, distractions, inexperience, and typing errors.
Conclusion. A national, voluntary medication error-reporting database cannot be used to determine the effectiveness of a CPOE system in reducing medication errors because of the variability in the number of reports from different institutions. However, it may provide valuable information on the specific types of errors related to CPOE systems.
Index terms: Computers; Databases; Dosage; Dosage forms; Errors, medication; Medication orders; Physicians; Reports; Toxicity
Purpose. The potential benefits and problems associated with computerized prescriber-order-entry (CPOE) systems were studied.
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