Implementation Of Computerized Physician Order Entry Research Articles

High Rates of Adverse Drug Events in a Highly Computerized Hospital

Numerous studies have shown that specific computerized interventions may reduce medication errors, but few have examined adverse drug events (ADEs) across all stages of the computerized medication process. We describe the frequency and type of inpatient ADEs that occurred following the adoption of multiple computerized medication ordering and administration systems, including computerized physician order entry (CPOE). Using explicit standardized criteria, pharmacists classified inpatient ADEs from prospective daily reviews of electronic medical records from a random sample of all admissions during a 20-week period at a Veterans Administration hospital. We analyzed ADEs that necessitated a changed treatment plan. Among 937 hospital admissions, 483 clinically significant inpatient ADEs were identified, accounting for 52 ADEs per 100 admissions and an incidence density of 70 ADEs per 1000 patient-days. One quarter of the hospitalizations had at least 1 ADE. Of all ADEs, 9% resulted in serious harm, 22% in additional monitoring and interventions, 32% in interventions alone, and 11% in monitoring alone; 27% should have resulted in additional interventions or monitoring. Medication errors contributed to 27% of these ADEs. Errors associated with ADEs occurred in the following stages: 61% ordering, 25% monitoring, 13% administration, 1% dispensing, and 0% transcription. The medical record reflected recognition of 76% of the ADEs. High rates of ADEs may continue to occur after implementation of CPOE and related computerized medication systems that lack decision support for drug selection, dosing, and monitoring.

Case Study: Challenges, Successes and Lessons Learned from Implementing Computerized Physician Order Entry (CPOE) at Two Distinct Health Systems: Implications of CPOE on the Pharmacy and the Medication-Use Process

The purpose of this case study is to provide an understanding of the divergent experiences, challenges, and successes associated with implementing Computerized Physician Order Entry (CPOE) at two distinct health systems utilizing the same software vendor. Pharmacy leaders at Lehigh Valley Hospital and Health Network in Allentown, PA and Montefiore Medical Center in the Bronx, NY describe the various strategies deployed for CPOE planning and implementation, the outcomes and impacts of CPOE implementation, and valuable experience. Improvements and efficiencies in the medication management process and time savings will be described. Additionally, reductions in medication prescribing errors and enhancements in medication cost savings secondary to improved medication utilization are delineated. The authors conclude that while the challenges associated with planning and implementing CPOE for medication management and its impact on the pharmacy are great, pharmacist involvement early in the strategic planning is vital to ensure a successful and safer electronic medication management process.

The impact of hospitalwide computerized physician order entry on medical errors in a pediatric hospital

Purpose Medication errors contribute significantly to the morbidity and costs of pediatric health care. The authors hypothesized that hospitalwide computerized physician order entry (CPOE) in a pediatric hospital would lead to a decrease in medication errors. Methods The authors retrospectively evaluated and prospectively analyzed inpatient discharge and usage and adverse drug event (ADE) rate data pre- and postintroduction of a hospitalwide implementation of CPOE in a tertiary care pediatric hospital. They compared pre- and postintervention ADEs (Student's t test) and computed the number needed to treat (NNT) analog. Results Over the 9-month study period, there were 45,615 in patient days and 8619 discharges. Pre-CPOE verbal order regulatory compliance was 80%, whereas post-CPOE increased to 95%. Transcription errors were eliminated. All ADEs pre-CPOE were 0.3 ± 0.04 per 1000 doses, whereas post-CPOE ADEs were 0.37 ± 0.05 per 1000 doses ( P = .3). Harmful ADEs pre-CPOE were 0.05 ± 0.017 per 1000 doses, while post-CPOE ADEs were 0.03 ± 0.003 per 1000 doses ( P = .05). Our NNT data demonstrate that CPOE would prevent 1 ADE every 64 (95% CI 25-100) patient days. Conclusions CPOE decreases harmful ADEs in a pediatric hospital, thus leading to increased patient safety. In addition, CPOE provides an automated system for monitoring and improving health care quality.

A tale of two hospitals: a sociotechnical appraisal of the introduction of computerized physician order entry in two Dutch hospitals.

We compared the implementation of computerized physician order entry (CPOE) in two Dutch hospitals, one being an academic medical center and the other a large regional non-academic hospital. Both implemented the TDS7000 system that was running on the same computer, located in the computing department of the academic medical center. The outcomes of the implementation were different. The introduction of CPOE in the university medical center failed, while it was a success in the non-academic hospital. An appraisal of the different outcomes is possible when we consider the implementation of information as a thorough social process in which the technical and the social are closely interrelated. Our findings suggest that organizational change associated with CPOE implementation should not focus on individual physician behavior but on medical work as a collaborative professional effort

Using Intranet-Based Order Sets to Standardize Clinical Care and Prepare for Computerized Physician Order Entry

The high cost of computerized physician order entry (CPOE) and physician resistance to standardized care have delayed implementation. An intranet-based order set system can provide some of CPOE's benefits and offer opportunities to acculturate physicians toward standardized care. INTRANET CLINICIAN ORDER FORMS (COF): The COF system at the Medical University of South Carolina (MUSC) allows caregivers to enter and print orders through the intranet at points of care and to access decision support resources. Work on COF began in March 2000 with transfer of 25 MUSC paper-based order set forms to an intranet site. Physician groups developed additional order sets, which number more than 200. Web traffic increased progressively during a 24-month period, peaking at more than 6,400 hits per month to COF. Decision support tools improved compliance with Centers for Medicare & Medicaid Services core indicators. Clinicians demonstrated a willingness to develop and use order sets and decision support tools posted on the COF site. COF provides a low-cost method for preparing caregivers and institutions to adopt CPOE and standardization of care. The educational resources, relevant links to external resources, and communication alerts will all link to CPOE, thereby providing a head start in CPOE implementation.

A Baseline Study of Medication Error Rates at Baylor University Medical Center in Preparation for Implementation of a Computerized Physician Order Entry System

ObjectiveTo determine baseline levels of medication errors and their root causes so as to highlight areas of potential process improvements and serve as a ruler against which to measure future improvements.DesignA prospective pharmacist intervention study determining errors in 1014 medication orders at Baylor University Medical Center. Only errors in the process of medication ordering were documented; errors in drug administration were not considered. Root causes of errors were examined.ResultsThe baseline medication error rate was 111.4 per 1000 orders (n = 1014). Most common were dosing errors (43.4 per 1000 orders), followed by frequency errors (19.7 per 1000 orders) and unavailable drug errors (12.8 per 1000 orders). Of the 113 total errors found, 52 (46%) had a transcription-based cause, i.e., an error in inputting the handwritten physician order into a computer system. System- or process-related root causes (such as duplicate orders or lack of crossover from one information system to another) accounted for 35.4% of the errors, and prescribing-based causes (such as wrong dosage or nonformulary drugs) accounted for 18.6% of errors.ConclusionsImplementing a computerized physician order entry (CPOE) system would eliminate order-entry transcription-based errors. Its ability to resolve system/process-based and prescribing-based root causes of error is not as clear. Furthermore, the modification of processes due to implementation of CPOE could lead to new types of errors. Present processes must be redesigned according to evidence-based medicine, and future processes must be anticipated as technological changes occur. Such efforts—rather than outright reliance on technology—are more likely to lead to an error-free environment after CPOE is implemented.

Understanding implementation: the case of a computerized physician order entry system in a large Dutch university medical center

Most studies of the impact of information systems in organizations tend to see the implementation process as a “rollout” of technology, as a technical matter removed from organizational dynamics. There is substantial agreement that the success of implementing information systems is determined by organizational factors. However, it is less clear what these factors are. The authors propose to characterize the introduction of an information system as a process of mutual shaping. As a result, both the technology and the practice supported by the technology are transformed, and specific technical and social outcomes gradually emerge. The authors suggest that insights from social studies of science and technology can help to understand an implementation process. Focusing on three theoretical aspects, the authors argue first that the implementation process should be understood as a thoroughly social process in which both technology and practice are transformed. Second, following Orlikowski's concept of “emergent change,” they suggest that implementing a system is, by its very nature, unpredictable. Third, they argue that success and failure are not dichotomous and static categories, but socially negotiated judgments. Using these insights, the authors have analyzed the implementation of a computerized physician order entry (CPOE) system in a large Dutch university medical center. During the course of this study, the full implementation of CPOE was halted, but the aborted implementation exposed issues on which the authors did not initially focus.

Impact of computerized physician order entry on clinical practice in a newborn intensive care unit.

To study the impact of computerized physician order entry (CPOE) on selected neonatal intensive care unit (NICU) practices. Retrospective review. Nursing units in an academic health system where CPOE has been implemented in adult services since 2000 and in the NICU since 2002. Data from 111 very-low-birth-weight (VLBW) infants born consecutively within 6 months before and 100 VLBW infants born within 6 months after the implementation of CPOE were evaluated. The study is based on pre- and post-CPOE comparisons in medication error rates and on the initiation to completion time intervals for pharmacy orders and radiology procedures. The specific data subsets that were compared included caffeine and gentamicin. Radiology turn-around time (order to image display) for the first chest and abdominal X-ray taken following endotracheal intubation and/or umbilical catheter placement was studied. Statistically significant (p<0.01) reductions were seen in medication turn-around times for the loading dose of caffeine in pre-CPOE (n=41, mean 10.5+/-9.8 SD hours) and post-CPOE (n=48, mean 2.8+/-3.3 SD hours). After CPOE implementation, the percentage of cases during each period where caffeine was administered before 2 and 3 hours increased from 10 to 35% and 12 to 63%, respectively. Accuracy of gentamicin dose at the time of admission for 105 (pre-CPOE) and 92 (post-CPOE) VLBW infants was determined. In the pre-CPOE period, 5% overdosages, 8% underdosages, and 87% correct dosages were identified. In the post-CPOE, no medication errors occurred. Accuracy of gentamicin dosages during hospitalization at the time of suspected late-onset sepsis for 31 pre- and 28 post-CPOE VLBW infants was studied. Gentamicin dose was calculated incorrectly in two of 31 (6%) pre-CPOE infants. No such errors were noted in the post-CPOE period. Radiology response time decreased significantly from the pre-CPOE (n=107, mean 42+/-12 SD minutes) to post-CPOE (n=95, mean 32+/-16 SD minutes). The implementation of CPOE in our NICU resulted in a significant reduction in medication turn-around times and medication errors for selected drugs, and a decrease in ancillary service (radiology) response time. In spite of the complexities of medication orders in pediatric populations, commercially available software programs for CPOE can successfully be adjusted to accommodate NICU needs and to beneficially impact clinical practice.

Adding insight: a qualitative cross-site study of physician order entry.

The research questions, strategies, and results of a six-year qualitative study of computerized physician order entry implementation (CPOE) at successful sites are reviewed over time. The iterative nature of qualitative inquiry stimulates a consecutive stream of research foci which, with each iteration, add further insight into the overarching research question. A multidisciplinary team of researchers studied CPOE implementation in four organizations using a multi-method approach to address the question "what are the success factors for implementing CPOE?" Four major themes emerged after studying three sites; ten themes resulted from blending the first results with those from a fourth site; and twelve principles were generated when results of a qualitative analysis of consensus conference transcripts were combined with the field data. The study has produced detailed descriptions of factors related to CPOE success and insight into the implementation process.

The effect of computerized physician order entry on medication errors and adverse drug events in pediatric inpatients.

Computerized physician order entry (CPOE) has the potential to reduce patient injury resulting from medication errors. We assessed the impact of a CPOE system on medication errors and adverse drug events (ADEs) in pediatric inpatients. A retrospective cohort study. Tertiary care pediatric hospital. Pediatric inpatients on 3 medical and 2 surgical wards. CPOE system implemented on 2 medical wards and compared with 1 medical and 2 surgical wards that continued to use hand written orders. Rate of medication error and ADEs before and after CPOE implementation. In 6 years, a total of 804 medication errors were identified with 18 ADEs, resulting in patient injury among 36 103 discharges and 179 183 patient days. The overall medication error rate (MER) was 4.49 per 1000 patient days. Before the introduction of CPOE, the MERs of the intervention versus control wards were indistinguishable (ratio = 0.93; 95% confidence interval [CI] = 0.76, 1.13). After the introduction of CPOE, the MER was 40% lower on the intervention than on the control wards (ratio = 0.60; 95% CI = 0.48, 0.74). On average, 490 patient days are required to see the benefit of one less medication error using CPOE. We did not demonstrate a similar effect of CPOE for ADEs (ratio of rate ratios = 1.30; 95% CI 0.47, 3.52). The introduction of a commercially available physician computer order entry system was associated with a significant decrease in the rate of medication errors but not ADEs in an inpatient pediatric population.

Understanding hospital readiness for computerized physician order entry.

Many hospitals in the United States are in early stages of decision making and planning to implement computerized physician order entry (CPOE) to improve patient safety and quality of care. The targeted processes and the software for CPOE are complex, and implementation is a large-scale change effort for most hospitals. Hospitals can increase the likelihood of success by understanding and addressing gaps in CPOE readiness. ASSESSING CPOE READINESS: A CPOE readiness assessment tool was developed that includes several different components: external environment; organizational leadership, structure, and culture; care standardization;, order management; access to information; information technology composition; and infrastructure. The presence or absence of these indicators in a particular hospital was determined by on-site interviews, walkarounds with direct observations, and document review. Assessment results for the first 17 hospitals (bed size, 75-906 beds) indicated that the lowest average component score was in care standardization, while the highest average component score was in organizational structure and function. Organizational culture and the order management process also had low average scores. This CPOE readiness assessment revealed significant gaps in all the hospitals examined. Identifying these gaps and addressing them before CPOE implementation can reduce risks. Organizations need to develop expertise at accomplishing and sustaining change; understanding and building CPOE readiness is an important first step.