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Ross Koppel, PhD; Joshua P. Metlay, MD, PhD; Abigail Cohen, PhD; Brian Abaluck, BS; A. Russell Localio, JD, MPH, MS; Stephen E. Kimmel, MD, MSCE; Brian L. Strom, MD, MPH

JAMA. 2005;293:1197-1203.

Context  Hospital computerized physician order entry (CPOE) systems are widely regarded as the technical solution to medication ordering errors, the largest identified source of preventable hospital medical error. Published studies report that CPOE reduces medication errors up to 81%. Few researchers, however, have focused on the existence or types of medication errors facilitated by CPOE.

Objective  To identify and quantify the role of CPOE in facilitating prescription error risks.

Design, Setting, and Participants  We performed a qualitative and quantitative study of house staff interaction with a CPOE system at a tertiary-care teaching hospital (2002-2004). We surveyed house staff (N = 261; 88% of CPOE users); conducted 5 focus groups and 32 intensive one-on-one interviews with house staff, information technology leaders, pharmacy leaders, attending physicians, and nurses; shadowed house staff and nurses; and observed them using CPOE. Participants included house staff, nurses, and hospital leaders.

Main Outcome Measure  Examples of medication errors caused or exacerbated by the CPOE system.

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.

Conclusions  In this study, we found that a leading CPOE system often facilitated medication error risks, with many reported to occur frequently. As CPOE systems are implemented, clinicians and hospitals must attend to errors that these systems cause in addition to errors that they prevent.

Author Affiliations: Department of Sociology (Dr Koppel), Department of Medicine, Cardiovascular Division (Dr Kimmel) and General Medicine Division (Drs Metlay and Strom), Center for Clinical Epidemiology and Biostatistics (Drs Koppel, Metlay, Cohen, Kimmel, and Strom and Mr Localio), Department of Biostatistics and Epidemiology (Drs Metlay, Kimmel, and Strom and Mr Localio), Department of Pharmacology (Dr Strom), Center for Education and Research in Therapeutics (Drs Metlay and Strom and Mr Localio), University of Pennsylvania School of Medicine (Mr Abaluck), Philadelphia; and Center for Health Equity Research and Promotion, Department of Veterans Affairs, Philadelphia (Dr Metlay).

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