CPOE Systems Fail Leapfrog Test

A web-based simulation found that computerized physician order entry systems missed one-half of routine medication order errors and a third of potentially fatal order errors.
CPOE systems, on average, missed one half of routine medication order errors and a third of potentially fatal order errors during a study The Leapfrog Group conducted of 214 hospitals using its web-based simulation tool.

Leapfrog CEO Leah Binder characterized the results as "disturbing."

Hospitals participating in the study - conducted between June 2008 and January 2010 - included urban, rural, and pediatric. Each adult hospital was given a scenario of 10 test patients and 50 medication orders; pediatric hospitals received 10 test patients and 51 medication orders. Each of the orders in the test scenario would result in an adverse drug event, and some of the test orders would result in a potentially fatal medication error.

Of the 214 hospitals analyzed for the report, 187 hospitals completed an adult CPOE test and 37 hospitals completed a pediatric test. Ten hospitals completed both an adult and pediatric test resulting in 224 total CPOE tests and 10,447 total medication orders processed through hospital CPOE systems.

On a positive note, of the 102 hospitals that retook the test following a six-month interval, 94 percent showed some level of improvement. During the time between tests, hospitals adjusted their systems and protocols, said Binder. "I visited four of the organization that retook the test and asked them about their improvement process," she said. "They convened pharmacy and the medical staff to go through and reconsider some of the automatic alerts and system features that created the mistakes."

Leapfrog provided the organizations with a detailed report on the errors so they could be studied and addressed. Added Barbara Rudolph, senior science director, Leapfrog, "Sometimes it was found certain medications should have been alerted at a higher level, or they were not coming directly back to the doctors at the time they were entering the order."

Two of the four organizations that Binder visited worked with their CPOE vendors on the adjustments. "That's certainly something I would expect them to do," she added.

A key finding of the study, according to David Knowlton - president & CEO of the New Jersey Health Care Quality Institute and Chair of Leapfrog's Board of Directors - was that CPOE systems require customization and continuous monitoring to be effective. "These systems are not plug and play," he explained, calling on the federal government to institute monitoring requirements as part of the HITECH Meaningful Use program.

Leapfrog's formal recommendation to the government and industry reads: "For the sake of safe patient care, hospitals must test and monitor their CPOE systems on an ongoing basis to achieve true meaningful use. In addition, vendors and hospitals must collaborate more closely during the pre-implementation and implementation phases to ensure that best practices are shared and followed."

Added Binder, "The complexity of CPOE has to be honored." CIOs, she said, were at a disadvantage because they lacked a window into the effectiveness of their CPOE systems, something she said Leapfrog's tool could address. She also encouraged the industry to develop a shared repository of CPOE best practices which could be continually updated with new lessons learned. "Every CIO at every hospital in the country should not have to reinvent this wheel," she added.

Anthony Guerra is the founder and editor of, a site dedicated to serving the strategic information needs of healthcare CIOs. He can be reached at [email protected]

Editor's Choice
Brandon Taylor, Digital Editorial Program Manager
Jessica Davis, Senior Editor
John Abel, Technical Director, Google Cloud
Cynthia Harvey, Freelance Journalist, InformationWeek
Christopher Gilchrist, Principal Analyst, Forrester
Cynthia Harvey, Freelance Journalist, InformationWeek