The role of computerized decision support in reducing errors in selecting medicines for prescription: Narrative review

Drug Safety

Volumn 34, Issue 4, 2011, Pages 289-298

  Baysari, Melissa T ^a,b   Westbrook, Johanna ^a   Braithwaite, Jeffrey ^a   Day, Richard O ^a,b  

^a UNIVERSITY OF NEW SOUTH WALES   (Australia)

^b ST VINCENT S HOSPITAL   (Australia)

Author keywords

Computers; Medication errors; Prescribing.

Indexed keywords

CLINICAL DECISION MAKING; COMPUTERIZED PROVIDER ORDER ENTRY; DECISION SUPPORT SYSTEM; ELECTRONIC PRESCRIBING; HUMAN; INFORMATION PROCESSING; MEDICAL ERROR; MEDICAL RESEARCH; PRESCRIPTION; PRIORITY JOURNAL; REVIEW;

ANIMALS; DECISION SUPPORT SYSTEMS, CLINICAL; DRUG PRESCRIPTIONS; HEALTH KNOWLEDGE, ATTITUDES, PRACTICE; HUMANS; MEDICATION ERRORS;

EID: 79952757497     PISSN: 01145916     EISSN: 11791942     Source Type: Journal    
DOI: 10.2165/11588200-000000000-00000     Document Type: Review

References (106)

1. Watcher RM. Understanding patient safety. New York (NY): The McGraw-Hill Companies, 2008.
2. Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety. Arch Intern Med 2003; 163: 1409-16. (Pubitemid 36758913)
3. Lewis PJ, Dorman T, Taylor D, et al. Prevalence, incidence and nature of prescribing errors in hospital inpatients: a systematic review. Drug Saf 2009; 32 (5): 379-89.
4. Franklin BD, Vincent C, Schachter M, et al. The incidence of prescribing errors in hospital inpatients: an overview of the research methods. Drug Saf 2005; 28 (10): 891-900. (Pubitemid 41428545)
5. Bates DW, Boyle DL, Vander Vliet M, et al. Relationship between medication errors and adverse drug events. J Gen Intern Med 1995; 10: 199-205.
6. Wilson DG, McArtney RG, Newcombe RG, et al. Medication errors in paediatric practice: insights from a continuous quality improvement approach. Eur J Pediatr 1998; 157: 769-74. (Pubitemid 28419108)
7. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. JAMA 1995; 274 (1): 29-34.
8. Van Doormaal JE, Van den Bernt PMLA, Zaal RJ, et al. The influence that electronic prescribing has on medication errors and preventable adverse drug events: an interrupted time series study. J AmMed Inform Assoc 2009; 16: 816-25.
9. Van Doormaal JE, Van den Bernt PMLA, Mol PGM, et al. Medication errors: the impact of prescribing and transcribing errors on preventable harm in hospital patients. Qual Saf Health Care 2009; 18: 22-7.
10. Stanhope N, Vincent C, Adams S, et al. Applying human factors methods to clinical risk management in obstetrics. Br J Obstet Gynaecol 1997; 104: 1225-32. (Pubitemid 27485488)
11. Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. JAMA 1995; 274 (1): 35-43.
12. Bobb A, Gleason K, Husch M, et al. The epidemiology of prescribing errors. Arch Intern Med 2004; 164: 785-92.
13. Dean B, Schachter M, Vincent C, et al. Causes of prescribing errors in hospital inpatients: a prospective study. Lancet 2002; 359: 1373-8. (Pubitemid 34442377)
14. Folli HL, Poole RL, Benitz WE, et al. Medication error prevention by clinical pharmacists in two children's hospitals. Pediatrics 1987; 79: 718-22. (Pubitemid 17087137)
15. Lesar TS, Briceland L, Delcoure K, et al. Medication prescribing errors in a teaching hospital. JAMA 1990; 263 (17): 2329-34. (Pubitemid 20143284)
16. Lesar TS, Briceland L, Stein DS. Factors related to errors in medication prescribing. JAMA 1997; 277 (4): 312-7. (Pubitemid 27045012)
17. Coombes ID, Stowasser DA, Coombes JA, et al. Why do interns make prescribing errors? A qualitative study. Med J Aust 2008; 188: 89-94.
18. Dean B, Schachter M, Vincent C, et al. Prescribing errors in hospital inpatients: their incidence and clinical significance. Qual Saf Health Care 2002; 11: 340-4. (Pubitemid 35463390)
19. Coombes ID, Pillans PI, Storie WJ, et al. Quality of medication ordering at a large teaching hospital. Aust J Hosp Pharm 2001; 31: 102-6. (Pubitemid 33673878)
20. Nichols P, Copeland T, Craib IA, et al. Learning from error: identifying contributory causes of medication errors in an Australian hospital. Med J Aust 2008; 188: 276-9.
21. Tully MP, Ashcroft DM, Dorman T, et al. The causes of and factors associated with prescribing errors: systematic review. Drug Saf 2009; 32: 819-36.
22. Reason J. Human error. Cambridge: Cambridge University Press, 1990.
23. Lederman RM, Parkes C. Systems failure in hospitals: using Reason's model to predict problems in a prescribing information system. J Med Syst 2005; 29 (1): 33-43. (Pubitemid 40386105)
24. Horsky J,KaufmanDR, OppenheimMI, et al. Aframework for analyzing the cognitive complexity of computer-assisted clinical ordering. J Biomed Inform 2003; 36 (1-2): 4-22. (Pubitemid 37206387)
25. Zhan C, Hicks RW, Blanchette CM, et al. Potential benefits and problems with computerized prescriber order entry: analysis of a voluntary medication error-reporting database. Am J Health Syst Pharm 2006; 63: 353-8. (Pubitemid 43244611)
26. Koppel R,Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA 2005; 293 (10): 1197-203. (Pubitemid 40327905)
27. Sintchenko V, Magrabi F, Tipper S. Are we measuring the right thing? Variables that affect the impact of computerised decision support on patient outcomes: a systematic review. Med Inform Internet Med 2007; 32 (3): 225-40. (Pubitemid 47299529)
28. Hunt DL, Haynes B, Hanna SE, et al. Effects of computerbased clinical decision support systems on physician performance and patient outcomes: a systematic review. JAMA 1998; 280 (15): 1339-46. (Pubitemid 28473723)
29. Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med 2006; 144: 742-52. (Pubitemid 46780634)
30. Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA 1998; 280 (15): 1311-6. (Pubitemid 28473716)
31. Terrell KM, Perkins AJ, Dexter PR, et al. Computerized decision support to reduce potentially inappropriate prescribing to older emergency department patient: a randomized controlled trial. J Am Geriatr Soc 2009; 57: 1388-94.
32. Han YY, Carcillo JA, Venkataraman ST, et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatr 2005; 116: 1506-12. (Pubitemid 46056501)
33. Nebeker JR, Hoffman JM, Weir CR, et al. High rates of adverse drug events in a highly computerized hospital. Arch Intern Med 2005; 165: 1111-6. (Pubitemid 40720734)
34. Campbell EM, Sittig DF, Ash JS, et al. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc 2006; 13 (5): 547-56. (Pubitemid 44292018)
35. Schedlbauer A, Prasad V, Mulvaney C, et al. What evidence supports the use of computerized alerts and prompts to improve clinicians' prescribing behavior? J Am Med Inform Assoc 2009; 16 (4): 531-8.
36. Reckmann MH, Westbrook J, Koh Y, et al. Does computerized provider order entry reduce prescribing errors for hospital inpatients? A systematic review. J Am Med Inform Assoc 2009; 16 (5): 613-23.
37. Donyai P, O'Grady K, Jacklin A, et al. The effects of electronic prescribing on the quality of prescribing. Br J Clin Pharmacol 2007; 65 (2): 230-7. (Pubitemid 351171262)
38. Judge J, Field TS, DeFlorio M, et al. Prescribers' responses to alerts during medication ordering in the long term care setting. J Am Med Inform Assoc 2006; 13 (4): 385-90. (Pubitemid 43947627)
39. Paterno MD, Maviglia SM, Gorman PN. Tiering drugdrug interaction alerts by severity increases compliance rates. J Am Med Inform Assoc 2009; 16: 40-6.
40. Galanter WL, Didomenico RJ, Polikaitis A. A trial of automated decision support alerts for contraindicated medications using computerised physician order entry. J Am Med Inform Assoc 2005; 12 (3): 269-74. (Pubitemid 40602978)
41. Kawamoto K, Houlihan CA, Balas A, et al. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ 2005; 330 (7494): 765-8. (Pubitemid 40522338)
42. Pearson S, Moxey A, Robertson J, et al. Do computerised clinical decision support systems for prescribing change practice? A systematic review of the literature (1990-2007). BMC Health Serv Res 2009; 9: 154.
43. Van der Sijs H, Aarts J, Vulto A, et al. Overriding of drug safety alerts in computerized physician order entry. J Am Med Inform Assoc 2006; 13 (2): 138-47. (Pubitemid 43332904)
44. Kushniruk AW, Patel VL. Cognitive evaluation of decision making processes and assessment of information technology in medicine. Int JMed Inform 1998; 51 (2-3): 83-90. (Pubitemid 28454526)
45. Kaplan B. Evaluating informatics applications - some alternative approaches: theory, social interactionism, and call for methodological pluralism. Int JMed Inform 2001; 64 (1): 39-56. (Pubitemid 32982865)
46. Ash JS, Berg M, Coiera EW. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc 2004; 11 (2): 104-12. (Pubitemid 38327498)
47. Beuscart-Zephir MC, Pelayo S, Anceaux F, et al. Impact of CPOE on doctor-nurse cooperation for the medication ordering and administration process. Int J Med Inform 2005; 74: 629-41. (Pubitemid 41024941)
48. Larum H, Ellingsen G, Faxvaag A. Doctors' use of electronic medical records systems in hospitals: cross sectional survey. BMJ 2001 Dec 8; 323 (7325): 1344-8. (Pubitemid 33152214)
49. Lee F, Teich JM, Spurr CD, et al. Implementation of physician order entry: user satisfaction and self reported usage patterns. J Am Med Inform Assoc 1996; 3: 42-55. (Pubitemid 126445010)
50. Glassman PA, Simon B, Belperio P, et al. Improving recognition of drug interactions: benefits and barriers to using automated drug alerts. Med Care 2002; 40 (12): 1161-71.
51. Magnus D, Rodgers S, Avery AJ. GP's views on computerized drug interaction alerts: questionnaire survey. J Clin Pharm Ther 2002; 27: 377-82. (Pubitemid 35286237)
52. Murff HJ, Kannry J. Physician satisfaction with two order entry systems. J Am Med Informs Assoc 2001; 8 (5): 499-511.
53. Feldstein A, Simon S, Schneider J, et al. How to design computerized alerts to ensure safe prescribing practices. Jt Comm J Qual Saf 2004; 30: 602-13.
54. Van der Sijs H, Aarts J, Gelder TV, et al. Turning off frequently overridden drug alerts: limited opportunities for doing it safely. J Am Med Inform Assoc 2008; 15 (4): 439-48. (Pubitemid 351885159)
55. Weir CR, Nebeker JJR, Hicken BL, et al. A cognitive task analysis of information management strategies in a computerized provider order entry environment. J Am Med Inform Assoc 2007; 14 (1): 65-75. (Pubitemid 44920374)
56. Shachak A, Hadas-Dayagi M, Ziv A, et al. Primary care physicians' use of an electronic medical record system: a cognitive task analysis. J Gen Intern Med 2009; 24 (3): 341-8.
57. Skitka LJ. Automation: decision aid or decision maker. Washington, DC: National Aeronautics and Space Administration, 1998.
58. Mosier KL, Skitka LJ. Human decision makers and automation decision aids: made for each other? In: Parasuraman R, Mouloua M, editors. Automation and human performance: theory and applications. Mahwah (NJ): Lawrence Erlbaum Associates, 1996: 201-20.
59. Chinburapa V, Larson LN, Brucks M, et al. Physician prescribing decisions: the effects of situational involvement and task complexity on information acquisition and decision making. Soc Sci Med 1993; 36 (11): 1473-82. (Pubitemid 23177795)
60. Kuipers B, Moskowitz AJ, Kassirer JP. Critical decisions under uncertainty: representation and structure. Cogn Sci 1988; 12 (2): 177-210.
61. Schumock GT, Walton SM, Park HY, et al. Factors that influence prescribing decisions. Ann Pharmacother 2004; 38: 557-62. (Pubitemid 38352213)
62. Pearson S, Rolfe I, Smith T. Factors influencing prescribing: an intern's perspective. Med Educ 2002; 36: 781-7. (Pubitemid 35002003)
63. Campo K, Staebel OD, Gijsbrechts E, et al. Physicians' decision process for drug prescription and the impact of pharmaceutical marketing mix instruments. Health Mark Q 2006; 22 (4): 73-107. (Pubitemid 43945575)
64. Segal R, Hepler CD. Drug choice as a problem-solving process. Med Care 1985; 23 (8): 967-76. (Pubitemid 15000097)
65. Becker MH, Stolley PD, Lasagna L, et al. Differential education concerning therapeutics and resultant physician prescribing patterns. JMed Educ 1972; 47 (2): 118-27.
66. Denig P, Haaijer-Ruskamp FM, Zijsling DH. How physicians choose drugs. Soc Sci Med 1988; 27 (12): 1381-6. (Pubitemid 19000646)
67. Worthen DB. Prescribing influences. Br J Med Educ 1973; 7: 109-17.
68. Hemminki E. Review of literature on the factors affecting drug prescribing. Soc Sci Med 1975; 9 (2): 111-6.
69. Bradley CP. Decision making and prescribing patterns: a literature review. Fam Pract 1991; 8: 2762-87.
70. Anderson N, Fuller R, DudleyN. 'Rules of thumb' or reflective practive? Understanding senior physicians' decisionmaking about anti-thrombotic usage in atrial fibrillation. QJM 2007; 100 (5): 263-9. (Pubitemid 47062903)
71. Nutescu EA, Park HY, Walton SM, et al. Factors that influence prescribing within a therapeutic drug class. J Eval Clin Pract 2005; 11 (4): 357-65. (Pubitemid 41059317)
72. Reichert S, Simon T, Halm EA. Physicians' attitudes about prescribing and knowledge of the costs of common medications. Arch Intern Med 2000; 160: 2799-803.
73. Denig P, Haaijer-Ruskamp FM, Wesseling H, et al. Towards understanding treatment preferences of hospital physicians. Soc Sci Med 1993; 36 (7): 915-24. (Pubitemid 23132374)
74. Lambert BL, Salmon JW, Stubbings J, et al. Factors associated with antibiotic prescribing in a managed care setting: an exploratory investigation. Soc Sci Med 1997; 45 (12): 1767-79. (Pubitemid 27525979)
75. Ford JK, Schmitt N, Schechtman SL, et al. Process tracing methods: contributions, problems, and neglected research questions. Organ Behav Hum Decis Process 1989; 43 (1): 75-117.
76. Silver MS. Systems that support decision makers: description and analysis. West Sussex: John Wiley & Sons Ltd, 1991.
77. Montgomery H. Decision rules and the search for a dominance structure: towards a process model of decision making. In: Humphreys P, Svenson O, Vari A, editors. Analysing and aiding decision processes. Budapest: North-Holland Publishing Company, 1983.
78. Chu PC, Spires EE. The joint effects of effort and quality on decision strategy choice with computerized decision aids. Decis Sci 2000; 31 (2): 259-92.
79. Svenson O. Process descriptions of decision making. Organ Behav Hum Perform 1979; 23: 86-112.
80. Payne JW, Bettman JR, Johnson EJ. The adaptive decision maker. Cambridge: Cambridge University Press, 1993.
81. Hogarth R. Judgement and choice: the psychology of decision. 2nd ed. Chichester: John Wiley & Sons, 1980.
82. Tamayo-Sarver JH, Dawson NV, Cydulka RK, et al. Variability in emergency physician decision making about prescribing opioid analgesics. Ann Emerg Med 2004; 43 (4): 483-93. (Pubitemid 38436538)
83. MancusoCA, RoseDN. A model for physicians' therapeutic decision making. Arch InternMed 1987; 147: 1281-5.
84. Moskowitz AJ, Kuipers B, Kassirer JP. Dealing with uncertainty, risks, and tradeoffs in clinical decisions: a cognitive science approach. Ann Intern Med 1988; 108: 435-49.
85. Backlund L, Skaner Y, Montgomery H, et al. GPs' decisions on drug treatment for patients with high cholesterol values: a think-aloud study.BMC Med Inform Decis Mak 2004; 4: 23.
86. Tversky A, Kahneman D. Judgement under uncertainty: heuristics and biases. Science 1974; 185: 1124-31.
87. Cook RI, Woods DD. Operating at the sharp end: the complexity of human error. In: Bogner MS, editor. Human error in medicine. Hillsdale (NJ): Lawrence Earlbaum Associates, 1994.
88. Bornstein BH, Emler AC. Rationality in medical decision making: a review of the literature on doctors' decisionmaking biases. J Eval Clin Pract 2001; 7: 97-107. (Pubitemid 32489003)
89. Christenson C, Heckerling PS, Mackesy-Amiti ME, et al. Pervasiveness of framing effects among physicians and medical students. J Behav Decis Mak 1995; 8: 169-80.
90. Cohen H, Robinson ES, Mandrack M. Getting to the root of medication errors: survey results. Nursing 2003; 33 (9): 36-46.
91. Aberegg SK, Arkes HR, Terry PB. Failure to adopt beneficial therapies caused by bias in medical evidence evaluation. Med Decis Mak 2006; 26 (6): 575-82. (Pubitemid 44728773)
92. Flin R, Salas E, Strub M, et al., editors. Decision making under stress: emerging themes and applications. Aldershot: Ashgate, 1997.
93. Zachary WW, Ryder JM. Decision support systems: integrating decision aiding and decision training. In: Helander M, Landauer TK, Prabhu P, editors. Handbook of human-computer interaction. 2nd ed. Elsevier Science, 1997: 1235-58.
94. Westbrook J, Woods A, Rob M, et al. Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med 2010; 170 (8): 683-90.
95. Westbrook J, Coiera EW, Dunsmuir W, et al. The impact of interruptions on clinical task completion. Qual Saf Health Care 2010; 19 (4): 284-9.
96. Lipshitz R. Converging themes in the study of decision making in realistic settings. In: Klein GA, Orasanu J, Calderwood R, et al., editors. Decision making in action: models and methods. Norwood (NJ): Ablex Publishing Corporation, 1993: 103-37.
97. Spring B. Health decision making: lynchpin of evidencebased practice. Med Decis Mak 2008; 28 (6): 866-74.
98. Klein GA, Calderwood R, MacGregor D. Critical decision method for eliciting knowledge. IEEE Trans Syst Man Cybern 1989; 19 (3): 462-72. (Pubitemid 20607219)
99. Higgins MP, Tully MP. Hospital doctors and their schemas about appropriate prescribing. Med Educ 2005; 39 (2): 184-93. (Pubitemid 40278545)
100. Harries C, Evans JSBT, Dennis I. Measuring doctors' selfinsight into their treatment decisions. Appl Cogn Psychol 2000; 14 (5): 455-77.
101. Evans J, Harries C, Dennis I, et al. General practitioners' tacit and stated policies in the prescription of lipid lowering agents. Br J Gen Pract 1995; 45: 15-8.
102. Patel VL, Kaufman DR, Arocha JF. Emerging paradigms of cognition in medical decision-making. J Biomed Inform 2002; 35 (1): 52-75. (Pubitemid 35216431)
103. Todd P, Benbasat I. Evaluating the impact of DSS, cognitive effort, and incentives on strategy selection. Inform Syst Res 1999; 10 (4): 356-74.
104. Beach LR,Mitchell TR.Acontingencymodel for the selection of decision strategies. Acad Manage Rev 1978; 3 (3): 439-49.
105. Todd P, Benbasat I. An experimental investigation of the impact of computer based decision aids on decision making strategies. Inform Syst Res 1991; 2 (2): 87-115.
106. Sintchenko V, Coiera EW. Which clinical decisions benefit from automation? A task complexity approach. Int J Med Inform 2003; 70: 309-16 (Pubitemid 36959722)