JAMA report questions CPOE safety

April 18, 2005

Perhaps nothing is as professionally frustrating to today's health-system pharmacists as the gap between the promise and reality of computerized physician order entry (CPOE). Concern may have risen to a new level in March with publication of a report in the Journal of the American Medical Association that said CPOE could cause as many medication errors as it prevents. Add that to a growing awareness among R.Ph.s that many physicians hate the systems and the fact that most hospitals can't afford them, and CPOE's promise of improved patient safety seems a dream.

Perhaps nothing is as professionally frustrating to today's health-system pharmacists as the gap between the promise and reality of computerized physician order entry (CPOE). Concern may have risen to a new level in March with publication of a report in the Journal of the American Medical Association that said CPOE could cause as many medication errors as it prevents. Add that to a growing awareness among R.Ph.s that many physicians hate the systems and the fact that most hospitals can't afford them, and CPOE's promise of improved patient safety seems a dream.

"The first two days after the article was published, I had 15 calls from colleagues about its findings," said John Hingl, R.Ph., operations manager for pharmacy at Cincinnati Children's Hospital Medical Center. "It was a disturbing report."

No one is losing faith in CPOE's potential, said Douglas Scheckelhoff, M.S., ASHP's director of pharmacy practice sections. "A well-designed system remains the goal. CPOE can eliminate transcription and illegibility errors, but we still have a long way to go, especially in the integration of the decision support systems that make CPOE systems worth the cost."

Scheckelhoff's point reflects one of the two root causes for the disturbing findings in the article: CPOE-related data errors resulted from a lack of integration of the health system's information systems. That resulted in fragmented displays that prevented a coherent view of all of a patient's medications and pharmacy inventory displays that showed incorrect dosage guidelines, among other problems.

The other root cause was human-machine interface errors, primarily resulting from a computer demanding input in ways that differed from the way clinical work is organized. Inflexible formats repeatedly produced incorrect medication orders, sometimes several times a week. Worse yet, clinicians reported they could select the wrong patient file because names and drugs appeared close together and patients' names did not appear on all screens.

Although the JAMA report looked at only one CPOE system at a single hospital, it came on the heels of a January report issued by the United States Pharmacopeia. That report categorized more than 235,000 error reports submitted in 2003 by 570 healthcare facilities, the largest database of errors ever analyzed by USP. Computer entry mistakes-defined by USP as those caused by incomplete or incorrect entry of a drug by a licensed prescriber-was the fourth-leading cause of errors, accounting for 13%. Illegible handwriting was the 15th-leading cause, accounting for 2.9% of reported errors.

"Handwriting will move down the list as computerization becomes more widely implemented, but what's surprising is that computer entry errors are replacing handwriting," said Diane Cousins, R.Ph., VP of the USP Center for the Advancement of Patient Safety.

Disturbing, but not surprising, said Deborah Hauser, R.Ph., director of pharmacy at Albert Einstein Medical Center. "Pharmacists will always do a better job at order entry than physicians." She is supported in her views by one of the report's key findings: Medical staff tended to look to the CPOE system to determine minimal effective or usual dosage for infrequently used medications. But the system often only reflected dosage sizes available at the pharmacy.

CPOE systems will get better, said ASHP's Scheckelhoff, especially if R.Ph.s are involved in their design. "Usually, in all health systems, pharmacists are very involved in a system's design and its continuous improvement. It's the pharmacists who do the actual building," he noted.