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CPOES Miss 1 In 3 Potentially Fatal Medication Orders

Heather Comak, for HealthLeaders Media, July 1, 2010

Computer physician order entry systems (CPOES) can potentially miss half of routine medication orders and one third of potentially fatal medication orders, a report released by The Leapfrog Group shows. The report is based on a study of 214 hospitals that tested their CPOE systems using a web-based simulation tool between June 2008 and January 2010. The Leapfrog Group is a quality organization that uses the power of large purchasers to positively affect patient safety and quality in healthcare.

The simulation tool was used to see how often CPOE caught common medication errors. Adult hospitals involved in the study received ten sample patients and 50 medication orders and pediatric facilities received 10 sample patients and 51 medication orders. Most of the hospitals that adjusted their protocols and CPOE systems after using the tool improved their performance.

"Although this is a simulation using fictitious patients and medication orders, it should be a red flag for every hospital and information technology company in America," said Leah Binder, MA, MGA, CEO of The Leapfrog Group.  "The belief that simply buying and installing health information technology will automatically lead to safer and better care is a myth.  Hospitals and vendors must continue to work together over time to ensure the effectiveness and efficiency of CPOE."

As a result of this report, The Leapfrog Group is calling on the federal government to ensure that the definition of "meaningful use" require that CPOE systems be monitored on a regular basis. Meaningful use refers to a set of requirements regarding health information technology that hospitals and physicians must meet to receive incentive payments through Medicare and Medicaid. Leapfrog is also urging hospitals and vendors to work more closely in designing CPOE interfaces and incorporating the system into practice. It does believe that using CPOE correctly can save lives by catching potential medication errors.

All hospitals that voluntarily take part in The Leapfrog Group's Hospital Survey have the opportunity to use the web-based monitoring tool.

To view the full report, click here.


Heather Comak is a Managing Editor at HCPro, Inc., where she is the editor of the monthly publication Briefings on Patient Safety, as well as patient safety-related books and audio conferences. She is also is the Assistant Director of the Association for Healthcare Accreditation Professionals. Contact Heather by e-mailing hcomak@hcpro.com.

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