Computerized Physician Order Entry Systems Appear To Increase Risk for Some Medication Erorrs, Study Finds

Computerized physician order entry systems appear to increase risk for 22 forms of medication errors, despite the "conventional wisdom that computerized ordering systems significantly reduce medication errors," according to a study published on Wednesday in the Journal of the American Medical Association, the Baltimore Sun reports.

For the study, researchers from the University of Pennsylvania School of Medicine tracked medical residents and attending physicians at the Hospital of the University of Pennsylvania from 2002 to 2004 as they used the Eclipsys TDS CPOE system. Researchers also surveyed 261 medical residents about their use of the system.

The study, funded by the Agency for Healthcare Research and Quality, found:

• About 75% of participants said that they were uncertain about prescription drugs or dosages because they could not view all patient medications on one computer screen;
  
  
• More than 25% of participants said that patients in some cases did not receive antibiotics on time because the CPOE system does not have a reminder feature;
  
  
• Participants in some cases ordered prescriptions under incorrect patient names "because names and drugs were listed close together in small type and the patient's name did not appear on each screen," the Sun reports (Niedowski, Baltimore Sun, 3/9);
  
  
• Participants in some cases misread pharmacy inventory information as dosage recommendations;
  
  
• Participants in some cases ordered new prescriptions but failed to cancel previous orders;
  
  
• Participants in some cases ordered prescriptions for incorrect patients when other physicians failed to log out of the system (FitzGerald, Philadelphia Inquirer, 3/9).

Ross Koppel, a sociologist at the Center for Clinical Epidemiology and Biostatistics and lead author of the study, said that the medication errors identified in the study increased recovery times or injured patients, although no deaths resulted from the errors (Allen, Boston Globe, 3/9). Koppel said, "These systems force people to wrap themselves around the technology like a pretzel instead of making sure the technology is responsive to the people doing the work" (Lohr, New York Times, 3/9).

Brian Strom, a co-author of the study, said, "As society goes forward and does more and more computerization of health care, it's critically important that it be evaluated along the way and that it be refined along the way. All of the problems we found are soluble" (Baltimore Sun, 3/9).

David Bates of Brigham and Women's Hospital, who served as an adviser for the study, said that researchers should have examined medication error rates at the hospital before the installation of the CPOE system to determine whether the system increased or decreased the rates (Boston Globe, 3/9).

Allen Vaida, executive director of the Institute for Safe Medication Practices, also said that study did not examine the number of medication errors or whether patients experienced injuries. Vaida said, "We just hope people won't look at the study and say, 'See, I told you it doesn't work,'" (Philadelphia Inquirer, 3/9).

Fran Griffin -- director of patient safety projects at the Institute for Healthcare Improvement, which was not involved in the study -- said, "With any CPOE system, no matter how well it's designed, there will be new errors occurring that didn't exist in the handwritten system" (Baltimore Sun, 3/9).

AHRQ Director Carolyn Clancy said in a statement, "New health care information technology products usually go through an ongoing process of refinement and improvement as health care workers identify problems. Ideally, principles of human factors research, usability testing and workflow impact should all be considered before products are released into the workplace" (AHRQ release, 3/8).

Officials for Eclipsys said that the CPOE system has incorporated updates that "dramatically reduce" the potential for human errors, such as those identified in the study.

According to the Inquirer, the study "comes as consumer advocates, corporate leaders and the Bush administration are urging a transition from paper records to electronic files to improve patient care" (Philadelphia Inquirer, 3/9).

David Brailer, administration coordinator for health information technology, called the study a "useful wake-up call." However, he said, "The way health information technology is developed, the way it is implemented and the way it is used are what matter."

He added, "We're not ready yet to really accelerate investment and adoption. We have about a year's worth of work" (New York Times, 3/9).

In an editorial that accompanied the study, Robert Wears, an emergency physician at the University of Florida, wrote, "The reality is: If the system helps" health care providers "do their work better, they would love it and use it. If they don't love it and use it, it must be getting in their way."

Wears added that in many cases a physician is "thinking about 20 patients at the same time, he's already late for surgery, a nurse is talking to him on one hand, his beeper is going off. These (systems) just don't fit the real world" (Baltimore Sun, 3/9).

An abstract of the study is available online.

NPR's "All Things Considered" on Tuesday reported on the study. The segment includes comments from Koppel and Wears (Neighmond, "All Things Considered," NPR, 3/8). The complete segment is available online in RealPlayer.