Computerized Medication Order Errors Studied

Researchers want to learn the cause of mistakes related to computerized physician order entry systems so they can help software makers prevent them.
While computerized physician order entry can help improve patient safety, these systems are also frequently implicated in medication errors. A new research study is looking to identify why these computerized ordering mistakes occur, and how they might be prevented.

The study is underway as the U.S. government prepares to reward healthcare providers that demonstrate "meaningful use" of health IT systems, such as CPOE, starting in 2011 under the $20 billion-plus HITECH legislation of the American Recovery and Reinvestment Act.

The National Patient Safety Foundation recently awarded a nearly $100,000 grant to a research team from the Center for Patient Safety Research and Practice, located at the Brigham and Women's Hospital and Harvard Medical School, and Quantros Patient Safety Center, a federally certified patient safety organization. The researchers are investigating nearly 200,000 reports of medication errors in which CPOE was listed as a contributing factor.

Those 200,000 CPOE-related medication errors are among the 1.5 million medication errors that 800 hospitals and health systems voluntarily reported over the last several years to Medmarx, an adverse drug reaction and medication error comparative data repository managed by software and services firm Quantros.

The adverse drug reaction and medication error incidents were collected voluntarily and anonymously from 800 hospitals and healthcare organizations via Medmarx's Web-based reporting system.

The medication errors were self-reported by "people on the front lines" of hospitals and healthcare systems, said Dr. Gordon Schiff, principal researcher in the year-long study that kicked off about two months ago.

The research team will try to replicate the errors to see why they occur, as well as evaluate improvements CPOE vendors could consider to make their systems "more user friendly," said Schiff, who is also associate director of the Center for Patient Safety Research and Practice.

"We'll look at the 20 to 30 most reoccurring errors, and kick the tires of CPOE systems," said Schiff in an interview with InformationWeek. "We're not playing the blame game, but want to see how these errors happen, and see if [the industry] can put in safeguards," he said.

It's possible that some reported medication errors are caused by user mistakes that get blamed on systems, he said.

"We have to think of this thoughtfully and carefully, some people throw up their hands" in using CPOE because they are reluctant to change the way they work, he said.

Other times, users are improperly trained, or they might be novice users, versus more experienced, "super users," said Schiff.

The study will attempt to sort through the reported errors and examine how CPOE user interfaces and taxonomy can be "more fail-safe," he said.