Use Of Computerized Physician Order Entry Research Articles

Effect of Computerized Physician Order Entry and Clinical Decision Support System on Adverse Drug Events Prevention in the Emergency Department: A Systematic Review.

Objective: An adverse drug event (ADE) is an injury resulting from a medical intervention related to a drug. The emergency department (ED) is a ward vulnerable to more ADEs because of overcrowding. Information technologies such as computerized physician order entry (CPOE) and clinical decision support system (CDSS) may decrease the occurrence of ADEs. This study aims to review research that reported the evaluation of the effectiveness of CPOE and CDSS on lowering the occurrence of ADEs in the ED. Data Sources: PubMed, EMBASE, and Web of Science databases were used to find studies published from 2003 to 2018. The search was conducted in November 2018. Study Selection and Data Extraction: The search resulted in 1700 retrieved articles. After applying inclusion and exclusion criteria, 11 articles were included. Data on the date, country, type of system, medication process stages, study design, participants, sample size, and outcomes were extracted. Data Synthesis: Results showed that CPOE and CDSS may prevent ADEs in the ED through significantly decreasing the rate of errors, ADEs, excessive dose, and inappropriate prescribing (in 54.5% of articles); furthermore, CPOE and CDSS may significantly increase the rate of appropriate prescribing and dosing in compliance with established guidelines (45.5% of articles). Conclusion: This study revealed that the use of CPOE and CDSS can lower the occurrence of ADEs in the ED; however, further randomized controlled trials are needed to address the effect of a CDSS, with basic or advanced features, on the occurrence of ADEs in the ED.

Evaluating the Use of a CPOE for Chemotherapy Protocols.

Chemotherapy drugs are one of the most common causes of serious and fatal medication errors, especially during prescribing, where computerized physician order entry (CPOE) take on importance. This study proposes the description of the post-implementation status of a CPOE in a highly specialized hospital between January and June 2018, among patients older than 18 years. Results: a total of 8835 protocols were indicated using the specific CPOE (93% use rate over all protocols) 91% completed the administration, 1.2% were rejected by pharmacy, and 6.8% was canceled. The most frequent cause of rejection by pharmacy and cancellation by oncologist was an inadequate dose. Most of the protocols indicated using the CPOE implemented, with a reject by pharmacy rate of 1.2%, indicates the utility of CPOE as an error prevention strategy.

Toward a Common Goal: Improving Safety of Oral Chemotherapy Prescribing Practices at a Jurisdictional Level.

Extending the safety agenda from parenteral to oral chemotherapy was identified as a provincial improvement priority in the 2014-2019 Cancer Care Ontario (CCO) Systemic Treatment Provincial Plan. Elimination of handwritten prescriptions for oral chemotherapy was one of the specific goals and led to a provincial quality improvement (QI) initiative involving systemic treatment facilities across 14 regional cancer programs. The initiative was centrally organized by CCO but locally implemented by the regional partners. CCO provided templates and tools, such as preprinted orders (PPOs), project charters, and an evaluation plan, and facilitated cross-jurisdictional knowledge sharing and exchange. Regions had flexibility in determining their local implementation strategies and were responsible for conducting chart audits to evaluate implementation success. Each participating hospital completed 3 audits-at baseline, immediately after implementation (audit 1), and 1 year later (audit 2)-using either a clinic-based or an outpatient pharmacy-based assessment. Thirty-five facilities providing systemic treatment participated. At baseline, the provincial average for the use of computerized physician order entry (CPOE) or PPOs for prescribing oral chemotherapy was 71%. After implementation of the QI initiative, the provincial average for the use of CPOE or PPO increased to 91% at audit 1 and 95% at audit 2. Although not all facilities met the goal of 100% CPOE or PPO compliance, the QI initiative led to improvement in safe prescribing practices for oral chemotherapy. A coordinated QI approach between a central decision maker and local partners can be an effective strategy to encourage high-quality cancer care and promote a culture of safety across a jurisdiction.

Computerized Physician Order Entry (CPOE) in Reducing Medication Error: A Narrative Review

Medication error leads to death and injury every day, causing lower quality of life and spend almost 1% of total global health expenditure. One of the solution of to prescribing error is using technology such as Computer Physician Order Entry (CPOE). This study purpose is to assess the use of CPOE in reducing medication error. The research method is a review of the narrative literature using systematic research, with 14 included studies. CPOE systems in hospitals were found to be capable of reducing medication errors especially in prescribing and administrative stage. However, CPOE system can be associated with new types of medication error, therefore, CPOE system must considered human factor, tailored according to the need of the hospital, and continuous training to reduce medication error.

The impact of computerized physician order entry on prescription orders: A quasi-experimental study in Iran.

Background: One way to reduce medical errors associated with physician orders is computerized physician order entry (CPOE) software. This study was conducted to compare prescription orders between 2 groups before and after CPOE implementation in a hospital. Methods: We conducted a before-after prospective study in 2 intensive care unit (ICU) wards (as intervention and control wards) in the largest tertiary public hospital in South of Iran during 2014 and 2016. All prescription orders were validated by a clinical pharmacist and an ICU physician. The rates of ordering the errors in medical orders were compared before (manual ordering) and after implementation of the CPOE. A standard checklist was used for data collection. For the data analysis, SPSS Version 21, descriptive statistics, and analytical tests such as McNemar, chi-square, and logistic regression were used. Results: The CPOE significantly decreased 2 types of errors, illegible orders and lack of writing the drug form, in the intervention ward compared to the control ward (p< 0.05); however, the 2 errors increased due to the defect in the CPOE (p< 0.001). The use of CPOE decreased the prescription errors from 19% to 3% (p= 0.001), However, no differences were observed in the control ward (p<0.05). In addition, more errors occurred in the morning shift (p< 0.001). Conclusion: In general, the use of CPOE significantly reduced the prescription errors. Nonetheless, more caution should be exercised in the use of this system, and its deficiencies should be resolved. Furthermore, it is recommended that CPOE be used to improve the quality of delivered services in hospitals.

Relationship Between Clerical Burden and Characteristics of the Electronic Environment With Physician Burnout and Professional Satisfaction

ObjectiveTo evaluate associations between the electronic environment, clerical burden, and burnout in US physicians. Participants and MethodsPhysicians across all specialties in the United States were surveyed between August and October 2014. Physicians provided information regarding use of electronic health records (EHRs), computerized physician order entry (CPOE), and electronic patient portals. Burnout was measured using validated metrics. ResultsOf 6375 responding physicians in active practice, 5389 (84.5%) reported that they used EHRs. Of 5892 physicians who indicated that CPOE was relevant to their specialty, 4858 (82.5%) reported using CPOE. Physicians who used EHRs and CPOE had lower satisfaction with the amount of time spent on clerical tasks and higher rates of burnout on univariate analysis. On multivariable analysis, physicians who used EHRs (odds ratio [OR]=0.67; 95% CI, 0.57-0.79; P<.001) or CPOE (OR=0.72; 95% CI, 0.62-0.84; P<.001) were less likely to be satisfied with the amount of time spent on clerical tasks after adjusting for age, sex, specialty, practice setting, and hours worked per week. Use of CPOE was also associated with a higher risk of burnout after adjusting for these same factors (OR=1.29; 95% CI, 1.12-1.48; P<.001). Use of EHRs was not associated with burnout in adjusted models controlling for CPOE and other factors. ConclusionIn this large national study, physicians' satisfaction with their EHRs and CPOE was generally low. Physicians who used EHRs and CPOE were less satisfied with the amount of time spent on clerical tasks and were at higher risk for professional burnout.

Drug-Drug Interactions Among Hospitalized Children Receiving Chronic Antiepileptic Drug Therapy.

Children treated with chronic medications are at risk of drug-drug interactions (DDIs) when hospitalized with an acute illness and prescribed new medications. We aimed to measure the prevalence of potential DDIs (pDDIs) among hospitalized children treated with antiepileptic drugs (AEDs) and to evaluate the impact of computerized physician order entry (CPOE) on pDDIs. We analyzed a national sample of pediatric hospitalizations from 2005 to 2012 associated with administration of an AED and identified those prescribed a second medication with risk of a DDI. The prevalence of hospitalizations associated with a pDDI was calculated for each AED. We identified the drugs most commonly implicated in pDDIs and factors associated with pDDIs. Rates of pDDIs were measured in pre- and post-CPOE implementation periods. A pDDI was identified in 181 380 (41.7%) hospitalizations associated with the use of an AED, with 117 880 (27.1%) classified as severe pDDIs. AEDs most often implicated with a pDDI were phenobarbital, valproic acid, and phenytoin. Hospitalizations with pDDIs were associated with increased length of stay and a greater number of medications, ICU admissions, and operating room procedures. The implementation of CPOE did not result in a change in the rate of pDDIs (42.7% before versus 40.8% after; P = .48). Children treated with AEDs are at risk of pDDIs while hospitalized. The use of CPOE has not been associated with a significant decrease in the rate of pDDIs. Additional investigation to better define the impact of pDDIs and to advance development of clinical decision support within CPOE systems is warranted.

An Observational Study of the Impact of a Computerized Physician Order Entry System on the Rate of Medication Errors in an Orthopaedic Surgery Unit.

AimTo assess the impact of the implementation of a Computerized Physician Order Entry (CPOE) associated with a pharmaceutical checking of medication orders on medication errors in the 3 stages of drug management (i.e. prescription, dispensing and administration) in an orthopaedic surgery unit.MethodsA before-after observational study was conducted in the 66-bed orthopaedic surgery unit of a teaching hospital (700 beds) in Paris France. Direct disguised observation was used to detect errors in prescription, dispensing and administration of drugs, before and after the introduction of computerized prescriptions. Compliance between dispensing and administration on the one hand and the medical prescription on the other hand was studied. The frequencies and types of errors in prescribing, dispensing and administration were investigated.ResultsDuring the pre and post-CPOE period (two days for each period) 111 and 86 patients were observed, respectively, with corresponding 1,593 and 1,388 prescribed drugs. The use of electronic prescribing led to a significant 92% decrease in prescribing errors (479/1593 prescribed drugs (30.1%) vs 33/1388 (2.4%), p < 0.0001) and to a 17.5% significant decrease in administration errors (209/1222 opportunities (17.1%) vs 200/1413 (14.2%), p < 0.05). No significant difference was found in regards to dispensing errors (430/1219 opportunities (35.3%) vs 449/1407 (31.9%), p = 0.07).ConclusionThe use of CPOE and a pharmacist checking medication orders in an orthopaedic surgery unit reduced the incidence of medication errors in the prescribing and administration stages. The study results suggest that CPOE is a convenient system for improving the quality and safety of drug management.

Variability of antithrombotic dosing among veterans presenting with acute coronary syndrome.

BackgroundAntithrombotic therapy for acute coronary syndrome (ACS) patients is recommended by clinical practice guidelines. Appropriate dosing of antithrombotic therapy is necessary to ensure effectiveness and safety and is an American College of Cardiology/American Heart Association ST elevated myocardial infarction/non‐ST elevated myocardial infarction performance measure. This study describes the variability in dosing of unfractionated heparin (UH) and low‐molecular‐weight heparin (LMWH) in an integrated health care system with electronic medical records and computerized physician order entry (CPOE).Methods and ResultsThis was a mixed‐methods study of veterans presenting with ACS at 135 Veterans Health Administration hospitals from 2009 to 2011. Patients hospitalized with ACS and received antithrombotic therapy were included (n=36 682). The cohort was 98% male with an average age of 66 years and median body mass index (BMI) of 28.6. The average percentage of patients by hospital who received an above‐recommended dose of either antithrombotic was 7.5% and ranged 0% to 32.0%. By individual therapy, the average percentage of patients by hospital who received an above‐recommended dose of UH was 1.2% and LMWH was 12.9%. Risk‐adjusted analyses demonstrated that older age and higher BMI were associated with lower risk for receiving a dose above recommended levels. Additionally, there was an association between antithrombotic ordered by a resident and higher risk of the patient receiving an above‐recommended dose. Qualitative interviews supported the quantitative findings by highlighting the need to use current patient weight and the need to adequately train providers on the use of CPOE to improve antithrombotic dosing.ConclusionThis study found wide hospital variability in dosing of antithrombotics above the recommended level for patients treated for ACS.

Computerized Physician Order Entry Improves Compliance With a Manual Exchange Transfusion Protocol in the Pediatric Intensive Care Unit

To evaluate the use of a computerized physician order entry (CPOE) protocol on manual red blood cell (RBC) exchange transfusion in critically ill children with sickle cell disease. We conducted a retrospective study of children with sickle cell disease who received a manual RBC exchange transfusion before (2001 to 2008, n=22) and after (2008 to 2009, n=11) implementation of a CPOE protocol. Outcomes included compliance with protocol, percentage reduction in sickle hemoglobin, and peak hemoglobin during exchange. Compliance with the manual exchange protocol improved after introduction of CPOE (pre-CPOE: 20 protocol violations vs. post-CPOE: 3 violations, P=0.02). Percentage reduction in sickle hemoglobin also improved (pre-CPOE: 55% vs. post-CPOE: 70%, P=0.04), whereas peak hemoglobin during RBC exchange was similar (pre-CPOE: 12.0 g/dL vs. post-CPOE: 11.5 g/dL, P=0.25). However, hemoglobin levels after the mean of 7 hours of exchange were significantly higher pre-CPOE (pre-CPOE: 11.5 g/dL vs. post-CPOE: 10.5 g/dL, P=0.006). Use of CPOE for manual RBC exchange transfusion in children is associated with improved protocol compliance, improved reduction of sickle hemoglobin, and better maintenance of hemoglobin levels in a goal range during prolonged exchanges.

Impact of Computerized Physician Order Entry on Medication Prescription Errors in Patients Hospitalized in a Chest Diseases Ward

Background: Many adverse drug events are related to medication errors during the ordering process and may be preventable. Computerized physician order entry (CPOE) appears as an effective tool in reducing them. Methods: We conducted a before-after prospective study in a chest diseases ward of an academic medical center. We compared rates of medication errors in medical orders during three phases: one before (manual prescription) and two after implementation of CPOE, at one and two months after. Secondarily we assessed error characteristics, process of medication use management and economic impact. Results: We detected 422 medication errors in 3257 medications prescribed: 352 in manual prescription phase (34.9% error rate) versus 45 one month after CPOE implementation (4.1% error rate)-88.2% relative risk reduction (p<0.001) and 25 after two months (2.2% error rate)-93.7% relative risk reduction (p<0.001). Main causes of error using manual prescription were lapsus in the ordering stage (68%) while using CPOE were lack of technology management (66.7% after one month and 68% after two months). Errors fell significantly for all drug types when comparing electronic versus manual prescription. We also found a significant reduction of non-drug-related errors, from 14.2% without the use of CPOE to 0.8% with its use (p<0.001) and in the amount of time spent preparing medication in pharmacy department. On average monthly drug costs fell 30%. Conclusions: CPOE substantially reduces medication errors and non-drug-related errors as well as improves the process of medication use management and appears to have a positive economic impact

Impact of computerized physician order entry (CPOE) on PICU prescribing errors

Dear Editor, Prescribing errors frequently occur in pediatric intensive care units (PICUs), for which both lowand high-technology solutions have been evaluated [1, 2]. Computerized physician order entry (CPOE) systems, including clinical decision support (CDS), offer the potential to reduce prescribing error rates in PICUs, but only if well designed and implemented [2–4]. We examined frequency, types, and risk factors of PICU prescribing errors in relation to use of CPOE. This prospective study was performed in a 14-bed PICU of a tertiary children’s hospital using a homegrown CPOE system since 2001. Contemporaneously, orders could be handwritten, allowing comparison. Medication orders of all patients admitted between February 2008 and December 2010 were reviewed for prescribing errors. The study was performed in accordance with the institutional review board guidelines. A total of 718 patients were included with 22,280 medication orders, of which 15,136 (68 %) were handwritten and 7,144 (32 %) CPOE. Omission rates were 66 % in handwritten versus 24 % in CPOE orders. Writing by hand was a strong risk factor for omissions, but CPOE did not reduce the error rate to zero. This was mainly due to the possibility to enter free text into the CPOE system. Because an order has to be complete for the purpose of dose checking, we state that free text entry should be minimized. In our study 12,879 orders were complete and could be reviewed for dosing errors (i.e., dose more than 10 % below or above guideline therapeutic range). Dosing error rates were 21 % in handwritten and 21 % in CPOE orders. Strikingly, 81 % of these dosing errors were more than 10 % below rather than above the therapeutic range, as shown in Fig. 1, and mainly concerned underdosing of antibiotics and analgesics for example. Kadmon et al. [4] already advocated that CPOE in a PICU must be accompanied by CDS that checks medication overdosing. We add that prevention of underdosing should also be incorporated. Associations between dosing errors and covariates related to the patient, order, or drug were studied using logistic regression analysis with forward selection. Intermittent dosing was the strongest risk factor for dosing errors [ORadjusted 5.6 (95 % CI 3.2, 9.8)]. Additionally, all routes of administration related to intermittent dosing, e.g., oral, rectal, and pulmonary, were significantly associated with omissions and dosing errors compared to the parenteral route. Currently though, CPOE/CDS development for PICUs mainly aims to support fast, correct, and easy ordering of continuous infusions [5]. We add that support for intermittent dosing regimens is also required. In conclusion, we identified three important additional requirements for CPOE/CDS to further prevent PICU prescribing errors: (1) minimization of any free text entry that could limit CDS for dose calculation and/or dose

Effects of computerized physician order entry on medication turnaround time and orders requiring pharmacist intervention

Previous studies have demonstrated that computerized physician order entry (CPOE) of prescriptions reduces both turnaround time (TAT) and medication errors. However, these studies have been performed primarily in large academic centers with a relatively small number of medication orders. As such, many studies investigating the impact of CPOE on the level of pharmacist intervention have yielded conflicting results. The objective of this study was to examine the effects of CPOE on medication order TAT and the frequency of medication orders requiring pharmacist intervention in a community-based medical center. A prospective cohort study was conducted at a community-based medical center. A total of 24,767 prescriptions written for 940 patients over a six-month period were stratified into CPOE or non-CPOE (handwritten) cohorts. TAT between cohorts were tested using analysis of variance and Tukey's Honestly Significant Difference test. The number of orders requiring pharmacist intervention was compared between cohorts and tested using chi-square test or Fisher's exact test. Medication orders requiring pharmacist intervention were stratified by patient characteristics, therapeutic class, and types of medication error. Medication orders not using CPOE were approximately 8 times more likely to require pharmacist intervention (2.26% versus 0.29%; P < 0.001), with the majority of pharmacist interventions performed to prevent medication errors. The overall mean TAT for medication orders was significantly shorter in the CPOE group in comparison with the non-CPOE group (22.2 ± 86.5 min versus 81 ± 256.7 min; P < 0.001). CPOE orders nearly eliminated medication errors with wrong dosage forms and formulary issues. Medication orders entered via CPOE are associated with a significant reduction in medication TAT and less likely to require pharmacist intervention. Use of CPOE may improve quality of patient care and efficiency of health care delivery.

Potential medication errors associated with computer prescriber order entry

To assess the frequency of medication errors (ME) induced or enhanced by computerized physician order entry (CPOE). Error type, drug classes involved, specialty, patient outcome and system failures were also evaluated. Observational quantitative study in a large tertiary care medical center over March 2012 3 years after CPOE implementation. Pharmacists detected ME associated with CPOE (those that wouldn't have occurred if the clinician had prescribed manually) and unassociated in pharmacological treatments in inpatients of 13 specialties (421 beds). Main outcome measured were ME associated and unassociated with CPOE. We found 714 ME with 85.857 drug prescriptions (a 0.8 % error rate, 95 % CI 0.6-0.7). Percentage of error associated with CPOE was 77.7 %. The main types of error related to CPOE were wrong medication selection (20.9 %) and improper data placement (20.3 %). Failures with medications prescribed in primary care, unavailable in the hospital pharmacy, were involved in 21.6 % of all ME. Errors involving surgical specialties were double those involving medical specialties (1.2 vs. 0.6 %). Most ME associated with CPOE were potential errors (90 %). During the study system failures occurred four times. The use of CPOE minimises the occurrence of medication errors, however, they still occur. Most errors are associated with the CPOE technology. We therefore face a new challenge in the prevention of ME that require a change in strategy for patient safety. Continued training of prescribers, standardization of the electronic prescription programs and integration between computer applications in hospitals and with primary care should be a priority.

Prospective evaluation of the treatment of pain in the ED using computerized physician order entry

BackgroundTreatment of pain in the emergency department (ED) is a significant area of focus, as previous studies have noted generally inadequate treatment of pain in ED patients. Previous studies have not evaluated the impact of computerized physician order entry (CPOE) on the treatment of pain in the ED. We sought to evaluate treatment of pain before and after implementation of CPOE in an academic ED. MethodsWe prospectively enrolled a convenience sample of patients presenting to the ED with a pain-related complaint in 4-month periods before and after CPOE implementation. We compared numbers who received pain medications, time from registration to administration of pain medication, and repeat dosing of pain medication. ResultsSix hundred forty-six ED patients participated in the pre-CPOE period, whereas 592 patients participated post-CPOE. Similar numbers of patients received pain medications in the pre-CPOE and post-CPOE periods (55% vs 59%; P = .139), whereas those in the post-CPOE period were more likely to receive a repeat dose of pain medications (10.5% vs 17.6%; P < .001). ConclusionThe use of CPOE in the ED may offer modest benefits in the treatment of patients with pain-related complaints.

Medication Errors in Patients With Severe Chronic Kidney Disease and Acute Coronary Syndrome: The Impact of Computer-Assisted Decision Support

OBJECTIVE To evaluate the impact of computerized physician order entry (CPOE) with decision support on the frequency of antithrombotic medication errors in patients with chronic kidney disease (CKD) admitted with acute coronary syndrome (ACS) and to measure what effect it would have on in-hospital bleeding. PATIENTS AND METHODS We evaluated 80 patients with CKD who were admitted with ACS between January 1, 2009, and December 31, 2010, using either a standardized order set or CPOE with decision support to assess the frequency of medication errors and in-hospital bleeding. RESULTS Of the 80 patients, 47 were admitted with standard orders vs 33 with CPOE. In-hospital bleeding occurred in 13 patients: 10 in the standard orders group vs 3 in the CPOE group (P=.12). In-hospital bleeding occurred in 5 (63%) of 8 patients receiving a contraindicated antithrombotic medication compared with 8 (11%) of 72 patients receiving appropriate medications (P=.002); the corresponding length of stay was 12.0 days compared with 6.8 days (P=.10). Contraindicated medications were given to no patients in the CPOE group vs 8 patients (17%) in the standard orders group (P=.01). CONCLUSION Medication errors occur frequently in patients with CKD admitted with ACS and result in a high risk of in-hospital bleeding. Use of CPOE with decision support is feasible in the ACS setting and may lead to improved patient safety.

Doctors’ orders––If they’re electronic, do they improve patient satisfaction? A complements/substitutes perspective

Doctors’ orders entered with Computerized Physician Order Entry (CPOE) systems are designed to enhance patient care by standardizing routines that are intended to improve quality of healthcare. As with other health information technology (IT) performance studies, literature shows conflicting results regarding the CPOE–performance relationship. By adopting a more nuanced perspective and employing not just adoption but extent of use of CPOE, we first examine whether or not CPOE use improves patient satisfaction. Next, given that CPOEs are implemented in the backdrop of other hospital IT infrastructure, we examine how IT infrastructure impacts the relationship between CPOE use and satisfaction, testing both a complementary and substitution perspective. Finally, we examine the differential impact of CPOE use between academic and non-academic hospitals. Using data from 806 hospitals nationwide, we find a positive relationship between extent of CPOE use and patient satisfaction. Contrary to extant research, our results suggest this relationship is stronger in non-academic hospitals. We also find evidence that a hospital's IT infrastructure substitutes for CPOE use in its effect on patient satisfaction.

Computerized Physician Order Entry in the Critical Care Environment: A Review of Current Literature

The implementation of health information technology (HIT) is accelerating, driven in part by a growing interest in computerized physician order entry (CPOE) as a tool for improving the quality and safety of patient care. Computerized physician order entry could have a substantial impact on patients in intensive care, where the potential for medical error is high, and the clinical workflow is complex. In 2009, only 17% of hospitals had functional CPOE systems in place. In intensive care unit (ICU) settings, CPOE has been shown to reduce the occurrence of some medication errors, but evidence of a beneficial effect on clinical outcomes remains limited. In some cases, new error types have arisen with the use of CPOE. Intensive care unit workflow and staff relationships have been affected by CPOE, often in unanticipated ways. The design of CPOE software has a strong impact on user acceptance. Intensive care unit-specific order sets lessen the cognitive workload associated with the use of CPOE and improve user acceptance. The diffusion of new technological innovations in the ICU can have unintended consequences, including changes in workflow, staff roles, and patient outcomes. When implementing CPOE in critical care areas, both organizational and technical factors should be considered. Further research is needed to inform the design and management of CPOE systems in the ICU and to better assess their impact on clinical end points, cost-effectiveness, and user satisfaction.

Effect of computerized physician order entry (CPOE) on chemotherapy prescribing error.

6034 Background: CPOE systems have previously been reported to reduce prescription error. There are few studies of CPOE in oncology practice. We studied the effect of replacing manual prescribing (MP) by a specialized chemotherapy CPOE system, ChemoCare, on prescribing error in a hematology-oncology practice in a comprehensive cancer center. Methods: All errors made during a 12-week period prior to CPOE implementation detected at routine pre-treatment pharmacy checks were categorized according to error type, and were scored for severity using the U.K. National Patient Safety Agency risk matrix by a panel of 4 blinded adjudicators (2 pharmacists and 2 doctors) working independently of each other; conflicts were resolved by a fifth adjudicator. Errors involving chemotherapy and supportive care with the exception of anti-infectives were analyzed. An identical exercise was conducted 15 months later, 6 months following completion of CPOE implementation. Results: A total of 49 of 251 (19.5%) of MP prescriptions contained an error compared to 14 of 272 (5.2%) of CPOE prescriptions, a 73% reduction (2p<0.0001, chi squared). The number of errors judged as major or potentially catastrophic fell by 50% whilst those of moderate severity fell by 81% with the use of CPOE (table). The drug dose error-rate was reduced by 74%, from 7.2% to 1.8% of prescriptions (2p=0.003), with a similar fall in error involving prescribing the wrong drug or wrong number of drug doses. There was a change in the nature of errors made with CPOE prescribing with 50% (7) arising from incorrect use of the system. These included 4 cases of zero drug doses arising from a failure to enter height and weight data. Conclusions: CPOE prescribing of chemotherapy offers a substantial improvement in patient safety. Error severity Catastrophic Major Moderate Minor None Total MP CPOE MP CPOE MP CPOE MP CPOE MP CPOE MP CPOE Wrong regimen 0 0 1 1 0 0 0 0 0 0 1 1 Wrong dose 1 0 6 2 10 3 0 0 1 0 18 5 Wrong number of doses 0 0 3 1 1 0 1 0 0 0 5 1 Missing or wrong drug 0 0 0 2 2 0 3 0 1 0 6 2 Supportive care error 0 0 0 0 4 1 5 4 3 0 12 5 Miscellaneous 0 0 1 0 4 0 2 0 0 0 7 0 Total 1 0 11 6 21 4 11 4 5 0 49 14 No significant financial relationships to disclose.

Computerized Physician Order Entry - effectiveness and efficiency of electronic medication ordering with decision support systems.

Health political backgroundComputerized physician order entry (CPOE) systems are software to electronically enter medication orders. They can be equipped with tools for decision support (CDS). In Germany, various vendors offer such systems for hospitals and physicians’ offices. These systems have mostly been developed during the last five to ten years.Scientific backgroundCPOE-systems exist since the 1970’s. Usually, clinical decision support is integrated into the CPOE to avoid errors.Research questionsThis HTA-report aims to evaluate the effectiveness and efficiency of CPOE-/CDS-systems and their ethical, social and legal aspects. MethodsThe systematic literature search (27 international data bases) yielded 791 abstracts. Following a two-part selection process, twelve publications were included in the assessment.ResultsAll reviews and studies included in the present report show that the use of CPOE-/CDS-systems can lead to a reduction of medication errors. Minor errors can be eliminated almost completely. The effect of CPOE-/CDS-systems on the rate of adverse drug events (ADE) is evaluated in only two primary studies with conflicting results. It is difficult to compare the results of economical studies because they evaluate different settings, interventions and time frames. In addition, the documentation often is not fully transparent. All four studies included measure costs and effects from the perspective of a hospital or hospital affiliation. Concerning social aspects, the literature points at changes regard competing interests of technology and humans that result from the implementation of CPOE-systems. The experience of institutions in which the implementation of CPOE-systems leads to problems showed that the importance of considering the socio-organisational context had partly been underestimated.DiscussionCPOE-/CDS-systems are able to reduce the rate of medication errors when ordering medications. The adherence to guidelines, communication, patient care and personnel satisfaction can also be affected positively. However, the literature also reports negative effects, as through the use of CPOE-/CDS-systems new errors can be generated. This makes continuous revisions of the system, as well as data-updates necessary. Concerning the cost-benefit-ratio from the hospital perspective, the two qualitatively best economic studies show contradictory results. Therefore, a positive cost-benefit-ratio for individual hospitals cannot be assumed, particularly as the study results cannot be generalized.ConclusionsIf the implementation of CPOE-/CDS-systems is well planned and conducted, the system adapted to the needs of the institution and continuously reviewed, and data used are updated on a regular basis, the rate of medication ordering errors can be reduced considerably by using CPOE-/CDS-systems. However, it is not clear how this results in a reduction of ADE. Prospective, systematic multi-centre evaluation-studies with clear methodology are needed, which include an analysis of the user-friendliness and of social and technical aspects of the system. Such studies should evaluate the impact a CPOE-/CDS-system has on ADE-rates and mortality. A detailed description of the system used and of the hospital evaluated is essential. If possible, costs and cost effects should be surveyed and documented transparently.