What’s New in the Patient Safety World


October 2009      A Cautious View on CPOE


Though we have always been and continue to be strong advocates of CPOE (computerized physician order entry), we have always also been wary that data showing a reduction in serious medication errors and adverse outcomes has been scant. We’ve also pointed out the many unintended consequences of CPOE, BMV (bedside medication verification) and electronic medical records:


A new systematic review published in this month’s JAMIA (Reckmann 2009) also concludes that the evidence showing a reduction in medication errors by CPOE, particularly serious medication errors, is scant. The few studies that did demonstrate positive results either had very focused outcomes (i.e. only certain types of medication errors in select populations were studied) or the study populations were very small or there were methodological problems.


On the positive side, another study (Weingart 2009) looked at the Massachusetts experience on the effect of alerts on electronic prescribing in ambulatory care. Applying a modeling technique, it showed what most other studies have shown, i.e. that the vast majority of computerized alerts are ignored by physicians. But it did show that about 10% of the alerts accounted for 60% of the adverse drug events possibly avoided and 78% of the projected cost savings. This reinforces previous recommendations to focus on a relatively few alerts that pertain to the most serious events and avoid the problem of alert fatigue.


These studies should not dissuade you from implementing CPOE with clinical decision support in your organizations. But they serve as a reminder that you should not do so with blind faith. You need to look at the benefits and the risks, anticipate unintended consequences, and focus your efforts in those areas where the evidence base supports the biggest impact.





Reckmann MH, Westbrook JI, Koh Y, Lo C, Day RO. Does Computerized Provider Order Entry Reduce Prescribing Errors for Hospital Inpatients? A Systematic Review.
 J Am Med Inform Assoc 2009; 16: 613-623




Weingart SN, Simchowitz B, Padolsky H, et al. An Empirical Model to Estimate the Potential Impact of Medication Safety Alerts on Patient Safety, Health Care Utilization, and Cost in Ambulatory Care. Arch Intern Med. 2009;169(16):1465-1473













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