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Press Start: Lead an Empowered Life as a Clinical Laboratorian

CPOE Misses Errors

Published December 18, 2008 9:05 AM by Glen McDaniel
Computerized physician order entry (CPOE) is touted as a major improvement in patient safety, primarily as a result of the Institute of Medicine's 1999 report on medical errors.

As a direct result of this initiative a consortium of companies called the Leapfrog Group was formed. These companies preferentially direct their employees' healthcare to those institutions installing such systems as part of directives Leapfrog feels will improve patient care.

In recent study, Leapfrog found CPOE are failing to catch serious drug interactions and medication errors. For example, in one test, between 10 percent and 20 percent of simulated allergy interactions were missed by nurses, physicians and pharmacists. Some hospitals failed to catch a fatal medication order in the simulation.



Thanks for your comments. You have identified some significant and recurring problems with having a successful CPOE program. As laboratorians used to computers and rules, we find it easy to adopt new technology and regulations while many others just try to fight them.

I have tried to institute  computerized medical records (including CPOE) in 2 different organizations -including a multi-hospital system. Both cases were painful to say the least.

I have seen physicians recruit their colleagues to boycott the system rather than adopt it -even after the medical staff executive voted to make its use mandatory.

Some of the the biggest issues I ahve seen:

1. Complaints that CPOE is more time consuming than writing. That's true; but that's missing the point. CPOE  is intended to improve patient safety, not to make order entry faster

2. Physicians give verbal orders to nurses rather than do their own order entry. That creates its own set of opportunities for errors and is, therefore,  frowned on by Medicare and others who recommend the minimization of verbal orders

3. One physician I know would write orders on paper, and then have a nurse use the physician's password to  place orders in the computer. Talk about increased risk of transcriptiona dn other errors - not to mention a severe breach of IT rules.

4.  Many physicians would have nurses print out entire parts of the chart rather than navigate the computer system themselves.

5. Physicians would often "blow through" caution boxes that pop up to warn about possible drug interactions, counter indications etc. They can even defeat systems that require a written response to a caution.

I recall one physician who would simply enter his initials, another would just put a period to get the box to go away. In a couple of cases I recall one physician ordering a pregnancy test on a male. Another ordered digoxin ona  patient with an elevated heart rate and the patient coded. In both cases, they just "blew through" the caution boxes without reading the alerts.

Electronic medical records and CPOE are great  conveniences and can play a significant role in improving patient safety, but (as a friend of mine would say), they are merely tools; they are  not "idiot proof"

Glen McDaniel December 29, 2008 11:26 PM

I haven't found CPOE to work well; it is always a failure of implementation.  Mapping a paper process to an information system is either terribly complex or an outright mistake.  From what little I've seen, those trying to do it keep their paradigms and their prejudice for paper.  I think a radically new philosophy is needed to break ingrained error cycles.  That's asking a lot from professionals weaned on paper.

In practice what happens is drug interactions are clicked through by ward secretaries, nurses wand water jugs to verify patient identity, and old-fashioned hard copies are faxed by hand for review.  All the same layers remain between the physician and the patient with a few more tossed in.  That's what I've seen.

Maybe, they should ask the laboratory for help.  We like this sort of thing.

Scott Warner December 20, 2008 2:34 PM

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