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Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors

Posted Oct 30 2008 3:22pm

This is a very interesting article published in JAMA relating the role of Computerized Physician Order Entry as a cause of error. Many issues are discussed as potential causes of error.

Results:  We found that a widely used CPOE system facilitated 22 types of medication error risks. Examples include fragmented CPOE displays that prevent a coherent view of patients’ medications, pharmacy inventory displays mistaken for dosage guidelines, ignored antibiotic renewal notices placed on paper charts rather than in the CPOE system, separation of functions that facilitate double dosing and incompatible orders, and inflexible ordering formats generating wrong orders. Three quarters of the house staff reported observing each of these error risks, indicating that they occur weekly or more often. Use of multiple qualitative and survey methods identified and quantified error risks not previously considered, offering many opportunities for error reduction. JAMA -- Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors, March 9, 2005, Koppel et al. 293 (10): 1197.

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