What’s New in the Patient Safety World

June 2012

Leapfrog CPOE Simulation: Improvement But Still Shortfalls



A couple years ago The Leapfrog Group developed a tool to simulate problematic medication orders (see our July 27, 2010 Patient Safety Tip of the Week “EMR’s Still Have a Long Way to Go”). The tool was to be used by hospitals to assess the vulnerabilities of their CPOE systems to medication errors. Voluntary testing at over 200 hospitals (Leapfrog 2010) then revealed that about half of errors on “routine” medication orders were missed and almost a third of potentially fatal medication errors were also missed. Those hospitals adjusted their CPOE systems and protocols and nearly all showed improvement when retested.


A similar test was conducted in 2011 by over 250 hospitals (Leapfrog 2012). The rate of missed potentially fatal errors dropped to just over 1% but the rate of missed “routine” medication errors was still on aveage about one third.


The CPOE evaluation tool is an excellent tool to identify potential vulnerabilities. When applied in a constructive fashion it has been shown to lead to significant improvement of hospital CPOE systems.






The Leapfrog Group. Leapfrog Group Report on CPOE Evaluation Tool Results

June 2008 to January 2010. June 2010




The Leapfrog Group. Lack of Testing and Monitoring of Health IT by Hospitals and Vendors Potentially Jeopardizes Patients -- Hospital Performance Is Improving, but More Must Be Done. PR Newswire April 27, 2012
















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