Friday, February 06, 2015

This Is A Very Concerning Report Regarding Electronic Ordering Of Medications.

This appeared a few days ago:

Erroneous med errors 'sail through' CPOE systems

January 21, 2015 | By Susan D. Hall
Nearly 80 percent of erroneous medication orders could be entered in computerized physician order entry (CPOE) systems, and more than half "sailed right through," with little or no difficulty or warnings, according to research published at BMJ Quality & Safety.
The researchers found 10,060 CPOE-related errors reported to the U.S. Pharmacopeia MEDMARX reporting system. They developed a taxonomy of those errors, then tried to replicate them on 13 CPOE systems at 16 sites.
Only 26.6 percent of erroneous orders generated specific warnings; of those, 69 percent were passive alerts, such as information displayed or easily overridden or ignored. Another 29 percent required workarounds, such as adjusting the dosage, but nonetheless, still could be entered, according to the research.
Leading CPOE-related errors included missing or erroneous label directions, wrong dose or strength, scheduling problems and delays in medication processing or administration due to confusing orders. In addition, despite the ease found in entering erroneous orders, systems that issue too many alerts also can lead to "alert fatigue," the authors noted. They urged finding the right balance to ensure patients are protected.
And while tighter regulation of electronic health records and CPOE poses one approach, improved post-market surveillance is another, they stated.
Lots more here with links to the publication:
The full paper is available here:
Here is the abstract:

Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems

  1. G D Schiff1,2,
  2. M G Amato1,3,
  3. T Eguale1,2,4,
  4. J J Boehne1,
  5. A Wright1,2,
  6. R Koppel5,
  7. A H Rashidee6,
  8. R B Elson7,
  9. D L Whitney8,
  10. T-T Thach1,
  11. D W Bates1,2,9,
  12. A C Seger1,3
  • Received 8 September 2014
  • Revised 3 October 2014
  • Accepted 3 December 2014
  • Published Online First 16 January 2015


Importance Medication computerised provider order entry (CPOE) has been shown to decrease errors and is being widely adopted. However, CPOE also has potential for introducing or contributing to errors.
Objectives The objectives of this study are to (a) analyse medication error reports where CPOE was reported as a ‘contributing cause’ and (b) develop ‘use cases’ based on these reports to test vulnerability of current CPOE systems to these errors.
Methods A review of medication errors reported to United States Pharmacopeia MEDMARX reporting system was made, and a taxonomy was developed for CPOE-related errors. For each error we evaluated what went wrong and why and identified potential prevention strategies and recurring error scenarios. These scenarios were then used to test vulnerability of leading CPOE systems, asking typical users to enter these erroneous orders to assess the degree to which these problematic orders could be entered.
Results Between 2003 and 2010, 1.04 million medication errors were reported to MEDMARX, of which 63 040 were reported as CPOE related. A review of 10 060 CPOE-related cases was used to derive 101 codes describing what went wrong, 67 codes describing reasons why errors occurred, 73 codes describing potential prevention strategies and 21 codes describing recurring error scenarios. Ability to enter these erroneous order scenarios was tested on 13 CPOE systems at 16 sites. Overall, 298 (79.5%) of the erroneous orders were able to be entered including 100 (28.0%) being ‘easily’ placed, another 101 (28.3%) with only minor workarounds and no warnings.
Conclusions and relevance Medication error reports provide valuable information for understanding CPOE-related errors. Reports were useful for developing taxonomy and identifying recurring errors to which current CPOE systems are vulnerable. Enhanced monitoring, reporting and testing of CPOE systems are important to improve CPOE safety.
What this paper is suggesting is that there are systemic errors in CPOE systems which need to be fully understood and solutions identified and the widely disseminated.
Very worrying article indeed.

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