Computerised physician order entry-related medication errors: Analysis of reported errors and vulnerability testing of current systems

BMJ Quality and Safety

Volumn 24, Issue 4, 2015, Pages 264-271

  Schiff, Gordon ^a,b   Amato, M G ^a,c   Eguale, T ^a,b,d   Boehne, J J ^a   Wright, A ^a,b   Koppel, R ^e   Rashidee, A H ^f   Elson, R B ^g   Whitney, D L ^h   Thach, T T ^a   Bates, D W ^a,b,i   Seger, A C ^a,c  

^a BRIGHAM AND WOMEN S HOSPITAL   (United States)

^b HARVARD MEDICAL SCHOOL   (United States)

^c MASSACHUSETTS COLLEGE OF PHARMACY AND HEALTH SCIENCES   (United States)

^d MCGILL UNIVERSITY   (Canada)

^e UNIVERSITY OF PENNSYLVANIA   (United States)

^f Quantros   (United States)

^g The MetroHealth System   (United States)

^h BAYLOR COLLEGE OF MEDICINE   (United States)

ⁱ HARVARD SCHOOL OF PUBLIC HEALTH   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

CODING; COMPUTERIZED PROVIDER ORDER ENTRY; HUMAN; MEDICAL LITERATURE; MEDICATION ERROR; MEDICATION THERAPY MANAGEMENT; PATIENT SAFETY; QUALITY CONTROL; REVIEW; TAXONOMY; ELECTRONIC PRESCRIBING; FACTUAL DATABASE; PHYSICIAN; PHYSICIAN ORDER ENTRY SYSTEM; STATISTICS AND NUMERICAL DATA; UNITED STATES;

DATABASES, FACTUAL; ELECTRONIC PRESCRIBING; HUMANS; MEDICAL ORDER ENTRY SYSTEMS; MEDICATION ERRORS; PHYSICIANS; UNITED STATES;

EID: 84924968910     PISSN: 20445415     EISSN: None     Source Type: Journal    
DOI: 10.1136/bmjqs-2014-003555     Document Type: Review

References (25)

1. 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;280:1311-16
2. Schiff GD, Rucker TD. Computerized prescribing: building the electronic infrastructure for better medication usage. JAMA 1998;279:1024-9
3. Blumenthal D, Tavenner M. The "meaningful use" regulation for electronic health records. N Engl J Med 2010;363:501-4
4. Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA 2005;293:1197-203
5. Ash JS, Sittig DF, Dykstra R, et al. The unintended consequences of computerized provider order entry: findings from a mixed methods exploration. Int J Med Inf 2009;78 (Suppl 1):S69-76
6. Strom BL, Schinnar R, Aberra F, et al. Unintended effects of a computerized physician order entry nearly hard-stop alert to prevent a drug interaction: A randomized controlled trial. Arch Intern Med 2010;170:1578-83
7. IOM (Institute of Medicine). Health IT and patient safety: building safer systems for better care. Washington DC: The National Academies Press, 2012
8. BatesDW. Draft FDASIACommittee Report. 2013. http://www. healthit.gov/FACAS/sites/faca/files/FDASIARecommendations Draft030913-v2.pdf (accessed 7 Sep 2014
9. SantellJP, Hicks RW,McMeekin J, et al. Medication errors: experience of the United States Pharmacopeia (USP) MEDMARX reporting system. J Clin Pharmacol 2003;43:760-7
10. Hicks RSJ, Cousins DD,Williams RL. MEDMARX 5th Anniversary data report: A Chartbook of 2003 Findings and Trends 1999-2003. Rockville, MD: United States Pharmacopeia Center for the Advancement of Patient Safety, 2004
11. National Coordinating Council for Medication Error Reporting and Prevention. Types of Medication Errors, 2001. http://www.nccmerp.org/medErrorCatIndex.html (accessed 4 Oct 2013)
12. Strauss A, Corbin JM. Basics of qualitative research: grounded theory procedures and techniques. Newbury Park, California: Sage Publications, 1990
13. Abramson EL, Kaushal R. Computerized provider order entry and patient safety. Pediatr Clin N Am 2012; 59:1247-55
14. Gandhi TK, Weingart SN, Seger AC, et al. Outpatient prescribing errors and the impact of computerized prescribing. J Gen Intern Med 2005;20:837-41
15. Shah NR, Seger AC, Seger DL, et al. Improving acceptance of computerized prescribing alerts in ambulatory care. J Am Med Inform Assoc 2006;13:5-11
16. Phansalkar S, Edworthy J, Hellier E, et al. A review of human factors principles for the design and implementation of medication safety alerts in clinical information systems. J Am Med Inform Assoc 2010;17:493-501
17. Wright A, Sittig DF, Carpenter JD, et al. Order sets in computerized physician order entry systems: An analysis of seven sites. AMIA Annu Symp Proc 2010;2010:892-6
18. Wright A, Phansalkar S, Bloomrosen M, et al. Best practices in clinical decision support: the case of preventive care reminders. Appl Clin Inform 2010;1:331-45
19. Metzger J, Welebob E, Bates DW, et al. Mixed results in the safety performance of computerized physician order entry. Health Aff (Millwood) 2010;29:655-63
20. Hazell L, Shakir SA. Under-reporting of adverse drug reactions : A systematic review. Drug Saf 2006;29:385-96
21. Pal SN, Duncombe C, Falzon D, et al. WHO strategy for collecting safety data in public health programmes: complementing spontaneous reporting systems. Drug Saf 2013;36:75-81
22. Sittig DF, Singh H. Electronic health records and national patient-safety goals. N Engl J Med 2012;367:1854-60
23. Horsky J, Phansalkar S, Desai A, et al. Design of decision support interventions for medication prescribing. Int J Med Inf 2013;82:492-503
24. Horsky J, Schiff GD, Johnston D, et al. Interface design principles for usable decision support: A targeted review of best practices for clinical prescribing interventions. J Biomed Inform 2012;45:1202-16
25. McKibbon KA, Lokker C, Handler SM, et al. The effectiveness of integrated health information technologies across the phases of medication management: A systematic review of randomized controlled trials. J Am Med Inform Assoc 2012;19:22-30.