CPOE (computerized physician order entry) is widely hailed as an important solution for reducing medical errors. However, the study, led by Ross Koppel at the University of Pennsylvania, listed over twenty ways that CPOE made medical errors more likely to happen. In particular, medicines could be ordered for the wrong patient, sent to the wrong place, or delayed for more than 24 hours.
Koppels original intention was not to study CPOE, but the sources of medical prescribing errors made by young physicians in hospitals. He told eWEEK.com he was surprised when the doctors kept bringing up the CPOE system, until he looked at it himself.
"I shadowed people, and looked at the system, and interviewed them, and I understood what they meant. It was a clunky, clumsy system that could easily facilitate errors," Koppel said.
The problem is that vendors and administrators expect doctors to shape their practices to the software rather than the other way around, Koppel said. "[When] software doesnt work the way information flows in the hospital, they want doctors and hospital processes to wrap themselves like pretzels around the software."
Based on a survey of 88 percent of clinicians using the system, Koppels study found several ways CPOE could encourage errors, including several listed below.
- If a physician enters orders after midnight, say after evening rounds, medication intended for the coming morning will not arrive until the next morning.
- Names of patients are listed alphabetically in small font, making it easy to select the wrong patient.
- Clinicians are unsure of patients medications because all medications cannot be shown on a single screen.
- Some reminders are kept in paper charts and are often ignored, leading to gaps in medication.
- Drug dosage levels displayed by the CPOE do not reflect guidelines, but pharmacy inventory.
- Medications suspended for surgery must be re-entered and activated individually. Though nurses can change a patients status to "active," this will not affect medications.
- CPOE crashes and shut-downs delay orders and, if patients are moved to a different room when the system is out of service, cause medications to be sent to the wrong room.
- When medical procedures are ordered, cancelled, or modified, all accompanying medicines must be stopped, re-ordered, or modified separately. Also, ordering non-standard drugs requires a separate process that may be ignored, causing delays.
Though clinicians are ultimately responsible for clinical errors, Koppel said, clinical software must make it harder, not easier to make mistakes.
He could not recall any improvements made to the system during the time of his study, from 2002 to 2004. "I saw doctors trying to work around the software and getting very frustrated that it hadnt been adjusted to make it responsive to their needs."
Nonetheless, Koppel said he was in favor of CPOE systems. "There are some dumb programs and really poor integrations, but on balance they reduce hand-writing errors, speed up orders and are instantly available from anywhere."