A Risk Analysis Method to Evaluate the Impact of a Computerized Provider Order Entry System on Patient Safety

Journal of the American Medical Informatics Association

Volumn 15, Issue 4, 2008, Pages 453-460

  Bonnabry, Pascal ^a   Despont Gros, Christelle ^a   Grauser, Damien ^a   Casez, Pierre ^a   Despond, Magali ^a   Pugin, Deborah ^a   Rivara Mangeat, Claire ^a   Koch, Magali ^a   Vial, Martine ^a   Iten, Anne ^a   Lovis, Christian ^a  

^a UNIVERSITY HOSPITAL   (Switzerland)

Author keywords

[No Author keywords available]

Indexed keywords

ANTIBIOTIC AGENT;

ARTICLE; BIOMEDICAL TECHNOLOGY ASSESSMENT; COMPUTER PROGRAM; COMPUTER SYSTEM; COMPUTERIZED PROVIDER ORDER ENTRY SYSTEM; DRUG MONITORING; ELECTRONIC MEDICAL RECORD; ERGONOMICS; FOLLOW UP; HANDWRITING; HOSPITAL INFORMATION SYSTEM; HUMAN; MEDICAL TECHNOLOGY; MEDICATION ERROR; PATIENT MONITORING; PATIENT SAFETY; PRESCRIPTION; RISK ASSESSMENT; VITAL SIGN;

DRUG THERAPY, COMPUTER-ASSISTED; EVALUATION STUDIES AS TOPIC; HUMANS; MEDICAL ORDER ENTRY SYSTEMS; MEDICATION ERRORS; QUALITY ASSURANCE, HEALTH CARE; RISK ASSESSMENT; SAFETY MANAGEMENT;

EID: 45849153901     PISSN: 10675027     EISSN: None     Source Type: Journal    
DOI: 10.1197/jamia.M2677     Document Type: Article

References (35)

1. Brennan T.A., Leape L.L., Laird N.M., Hebert L., Localio A.R., Lawthers A.G., et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study. N Engl J Med 324 (1991) 370-376
2. Thomas E.J., Studdert D.M., Newhouse J.P., Zbar B.I., Howard K.M., Williams E.J., and Brennan T.A. Costs of medical injuries in Utah and Colorado. Inquiry 36 (1999) 255-264
3. Phillips D.P., Christenfeld N., and Glynn L.M. Increase in US medication-error deaths between 1983 and 1993. Lancet 351 (1998) 643-644
4. Institute of medicine. To err is human. Building a safer health system (1999), National Academy Press, Washington DC
5. Bates D.W., Cullen D.J., Laird N., Petersen L.A., Small S.D., Servi D., et al. Incidence of adverse drug event and potential adverse drug events. J Am Med Assoc 274 (1995) 29-34
6. Hassall T.H., and Daniels C.E. Evaluation of three types of control chart methods in dose error monitoring. Am J Hosp Pharm 40 (1983) 970-975
7. Garnerin P., Pellet-Meier B., Chopard P., Pernegger T., and Bonnabry P. Measuring human-error probabilities in drug preparation: a pilot simulation study. Eur J Clin Pharmacol 63 (2007) 769-776
8. Bayne T., and Bindler R. Effectiveness of medication calculation enhancement methods with nurses. J Nurs Staff Dev 13 (1997) 293-301
9. Oren E., Shaffer E.R., and Guglielmo B.J. Impact of emerging technologies on medication errors and adverse drug events. Am J Health-Syst Pharm 60 (2003) 1447-1458
10. Leape L.L., Bates D.W., Cullen D.J., et al. Systems analysis of adverse drug events. J Am Med Assoc 274 (1995) 35-43
11. Guchelaar H.J., and Kalmeijer M.D. The potential role of computerisation and information technology in improving prescribing in hospitals. Pharm World Sci 25 (2003) 83-87
12. Kaushal R., Shojania K.G., and Bates D.W. Effect of computerized physician order entry and clinical decision support systems on medication safety. A systematic review. Arch Intern Med 163 (2003) 1409-1416
13. Bates D.W., Leape L.L., Cullen D.J., Laird N., Petersen L.A., Teich J.M., et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. J Am Med Assoc 280 (1998) 1311-1316
14. Bates D.W., Teich J.M., Lee J., Seger D., Kuperman G.J., Ma'Luf N., et al. The impact of computerized physician order entry on medication error prevention. J Am Med Informatics Assoc 6 (1999) 313-321
15. Koppel R., Metlay J.P., Cohen A., Abaluck B., Localio A.R., Kimmel S.E., and Strom B.L. Role of computerized physician order entry system in facilitating medication errors. J Am Med Assoc 293 (2005) 1197-1203
16. Letters to the editor. J Am Med Assoc 294 (2005) 178-181
17. Han Y.Y., Carcillo J.A., Venkataraman S.T., Clark R.S., Watson R.S., Nguyen T.C., et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics 116 (2005) 1506-1512
18. Ammenwerth E., Talmon J., Ash J.S., Bates D.W., Beuscart-Zéphir M.C., Duhamel A., et al. Impact of CPOE on mortality rates-contradictory findings, important messages. Methods Inf Med 45 (2006) 586-593
19. Classen D., Avery A., and Bates D.W. Evaluation and certification of computerized provider order entry systems. J Am Med Informatics Assoc 14 (2007) 48-55
20. Ash J., Stavri P., and Kuperman G. A consensus statement on considerations for a successful CPOE implementation. J Am Med Informatics Assoc 10 (2003) 229-234
21. Zhan C., Hicks R., Blanchette C., Keyes M., and Cousins D. Potential benefits and problems with computerized prescriber order entry: analysis of a voluntary medication error-reporting database. Am J Health-Syst Pharm 63 (2006) 353-358
22. Bradley V., Steltenkamp C., and Hite K. Evaluation of reported medication errors before and after implementation of computerized practitioner order entry. J Healthc Inf Manag 20 (2006) 46-53
23. Upperman J.S., Staley P., Friend K., Neches W., Kazimer D., Benes J., and Wiener E.S. The impact of hospital wide computerized physician order entry on medical errors in a pediatric hospital. J Ped Surg 40 (2005) 57-59
24. Kilbridge P., Welebob E., and Classen D. Development of the Leapfrog methodology for evaluating hospital implemented inpatient computerized physician order entry systems. Qual Saf Health Care 15 (2006) 81-84
25. Crane J., and Crane F. Preventing medication errors in hospitals through a systems approach and technological innovation: a prescription for 2010. Hosp Topics 84 (2006) 3-8
26. Joint Commission on Accreditation of Healthcare Organizations. Medical errors, sentinel events, and accreditation. A report to the Association of Anesthesia Programs Directors (2000) 28 October
27. De Rosier J., Stalhandske E., Bagian J.P., and Nudell T. Using health care failure mode and effect analysis: the VA National Center for Patient Safety's prospective risk analysis system. Jt Comm J Qual Improv 28 (2002) 248-267
28. Institut for healthcare improvement. Failure modes and effects analysis (FMEA). http://www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/Tools/ Accessed [January 13, 2007]
29. Bonnabry P., Cingria L., Sadeghipour F., Ing H., Fonzo-Christe C., and Pfister R.E. Use of a systematic risk analysis method to improve security in the paediatric parenteral nutrition production. Qual Saf Health Care 14 (2005) 93-98
30. Bonnabry P., Cingria L., Ackermann M., Sadeghipour F., Bigler L., and Mach N. Use of a prospective risk analysis method to improve the safety of the cancer chemotherapy process. Int J Qual Health Care 18 (2006) 9-16
31. Williams E. The use of failure mode effect and criticality analysis in a medication error subcommittee. Hosp Pharm 29 (1994) 331-337
32. Gandhi T.K., Weingart S.N., Seger A.C., et al. Outpatient prescribing errors and the impact of computerized prescribing. J Gen Intern Med 20 (2005) 837-841
33. Robinson D.L., Heigham M., and Clark J. Using failure mode and effects analysis for safe administration of chemotherapy to hospitalized children with cancer. Jt Comm J Qual Patient Saf 32 (2006) 161-166
34. Van Tilburg C.M., Leistikow I.P., Rademaker C.M., Bierings M.B., and van Dijk A.T. Health care failure mode and effect analysis: a useful proactive risk analysis in a pediatric oncology ward. Qual Saf Health Care 15 (2006) 58-64
35. Kim G.R., Chen A.R., Arceci R.J., Mitchell S.H., Kokoszka K.M., Daniel D., and Lehmann C.U. Error reduction in pediatric chemotherapy. Computerized order entry and failure modes and effects analysis. Arch Pediatr Adolesc Med 160 (2006) 495-498