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5/21/2004

Customization Key to Successful CPOE

Kate Traynor

A recently published report advises hospitals to pinpoint the source of their medication errors before implementing a computerized prescriber-order-entry (CPOE) system and then customize the system to catch errors that are most likely to harm patients.1

In other words, said lead author Anne M. Bobb, just having a CPOE system in place does not guarantee patient safety. "It all depends on how you implement" the system, she said.

Bobb is a patient safety research pharmacist at Northwestern Memorial Hospital in Chicago, Illinois, a 700-bed facility that is working to implement a CPOE and electronic medical record system.

In the report, Bobb and her colleagues found that, for every 1000 orders, Northwestern averaged 62 errors, 64% of which occurred during admission of patients to the hospital.

"Most orders are written on day one" of the hospital stay, Bobb explained. She added that a CPOE system would not be likely to prevent errors on admission that result from "a misunderstanding of what the patient was on prior to admission, or lack of reconciliation between home medications and what [patients] are going to take in the hospital."

The report concluded that 64% of the errors examined during the study were likely to have been detected "by most currently available CPOE systems." Some 13% were categorized as unlikely to be detected by CPOE, and the remainder were classified as preventable with a CPOE system that includes advanced clinical decision support.

At Northwestern, 12% of all medication errors that occurred during the study period were deemed likely to cause patient harm, and 19% necessitated monitoring of the patient. According to the report, about a quarter of these "clinically significant" errors were classified as unlikely to have been detected by common CPOE systems, but 46% would be prevented by CPOE systems with advanced clinical decision support.

Bobb said she hopes the data generated by her study will enhance the rollout of CPOE at Northwestern.

"We are doing . . . a good job of collecting data on harm that happens here due to medical error," she said. "We're going to prioritize that for clinical decision support. So we will build our rules around the events that actually happen within our institution."

Kasey K. Thompson, ASHP's director of patient safety, said that, although CPOE can improve patient safety, health care providers should not view the technology as a way to instantly fix problems with the medication-use process.

"A wrong patient can still be selected in a CPOE system, as can a wrong drug from a drop-down menu," he said. "Sometimes, systems don't interface with other key systems in the hospital, such as the pharmacy system, which can and does currently cause major problems."

The Northwestern team's report stressed that, because CPOE systems do not catch all medication errors, clinical pharmacists should be involved in the medication-use process—a view shared by Thompson.

"Pharmacists understand the medication-use system better than anyone," he said. Thompson added that pharmacists should be "key members of the team when purchasing decisions are made and technology plans implemented."

David J. Hellmuth is administrative director of pharmaceutical services at Abington Memorial Hospital in Abington, Pennsylvania, which has had CPOE in place for nine years and is preparing to launch a second-generation system this fall.

Abington, winner of last year's American Hospital Association Quest for Quality prize for safety and innovation in patient care, has embraced the core principles of the Leapfrog Group. This coalition of 155 public and private organizations urges employers who provide health benefits to steer workers toward hospitals that adhere to certain quality and patient-safety practices. One such practice is the use of CPOE for at least 75% of the hospital's medication orders.

Hellmuth estimated that physicians enter 90–95% of the hospital's medication orders into Abington's current CPOE system. The remaining medication orders at the 500-bed hospital are telephoned in to the pharmacy by off-site physicians or conveyed orally by prescribers, such as operating-room physicians, who lack immediate access to the computerized system.

When the CPOE system was first installed, Hellmuth said, medical residents were the only physicians who were required to enter medication orders electronically. Electronic orders were also entered by pharmacists when they were asked by a physician to change a medication order.

Because use of the CPOE system was voluntary for most of the 600 physicians who practiced or had privileges at Abington, "there was a portion of the doctors who continued to write handwritten orders . . . which leads to error," Hellmuth said.

That changed with the publication of the Institute of Medicine's report "To Err Is Human: Building a Safer Health System." Hellmuth said that, after Abington's chief of staff read the report, he decided that mandatory CPOE "was something that we needed to do."

To ease the transition to CPOE, Abington purchased additional workstations, including some wireless units, to counter arguments from physicians who said they did not have timely access to a computer terminal to enter orders.

Hellmuth said that the hospital also designed custom order-entry screens, including personalized "order sets" containing physicians' most common medication, laboratory, and radiology orders.

"The hospital has gone to a great expense to expand technology here to ensure that we do utilize CPOE to the maximum," Hellmuth said.

Although the hospital did not collect baseline data that would have allowed the study of medication-error rates since paper orders were eliminated, Hellmuth said the CPOE system has clearly brought "a lot of improvements" to Abington.

Among these, he said, are reduced turnaround time for medication orders, fewer "allergy calls" to the pharmacy, and an end to misplaced paper orders.

Hellmuth explained that dealing with misplaced paper orders used to promote a "blame game" at Abington, placing the physician, nurses, and pharmacy staff at odds with each other.

The CPOE system has "cut down a lot of that type of blame," Hellmuth said.

"That's an important thing," he added. "That's patient safety. It's also patient satisfaction, employee satisfaction because you're getting things when you need them."

Despite the overall success of CPOE at Abington, Hellmuth said that orders with errors still arrive in the pharmacy. "Where errors still occur," he said, "is when [physicians] do typing" and enter an incorrect dosage strength, such as can occur when treating a pediatric patient.

Hellmuth described keyboard errors as "the soft underbelly of CPOE." He noted that the pharmacy's computer system has a dosage-range checking feature that flags incorrect dosages—a feature that will be available to physicians when the new CPOE system is in place.

Another potential source of errors occurs when physicians circumvent the CPOE system by writing paper orders for the clerical or nursing staff to transcribe into the system.

In an article describing Abington's implementation of mandatory CPOE, the hospital's chief information officer, Alison Ferren, stated that nurses had sometimes entered orders into the system for physicians "in an effort to be helpful."2

Ferren described the nurses' action as a "roadblock" to CPOE implementation because the physicians involved "did not become acclimated to the clinical information system." Ferren recommended that, when implementing a CPOE system, the nursing staff be encouraged to help physicians learn the system but not do the work for them.

Hellmuth said that physicians at Abington like the current CPOE system, which has been customized for their use. He added that the second-generation system, which will further integrate laboratory information and prescribing, will be even more useful to physicians.

After nearly a decade of experience using CPOE at Abington, Hellmuth said, he would not want to practice pharmacy anywhere without such a system in place.

"I really think [CPOE] enhances patient safety," he said. "It's starting to become more and more a standard of care."

  1. Bobb A, Gleason K, Husch M et al. The epidemiology of prescribing errors. Arch Intern Med. 2004; 164:785-92.
  2. Ferren AL. Gaining MD buy-in: physician order entry. J Healthc Inf Manag. 2002; 16 (2):66-70.