title: Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems.
abstract: OBJECTIVE
  Medication computerised provider order entry (CPOE) has been shown to decrease errors and is being widely adopted. However, CPOE also has potential for introducing or contributing to errors.
  
  
  OBJECTIVE
  The objectives of this study are to (a) analyse medication error reports where CPOE was reported as a 'contributing cause' and (b) develop 'use cases' based on these reports to test vulnerability of current CPOE systems to these errors.
  
  
  METHODS
  A review of medication errors reported to United States Pharmacopeia MEDMARX reporting system was made, and a taxonomy was developed for CPOE-related errors. For each error we evaluated what went wrong and why and identified potential prevention strategies and recurring error scenarios. These scenarios were then used to test vulnerability of leading CPOE systems, asking typical users to enter these erroneous orders to assess the degree to which these problematic orders could be entered.
  
  
  RESULTS
  Between 2003 and 2010, 1.04 million medication errors were reported to MEDMARX, of which 63 040 were reported as CPOE related. A review of 10 060 CPOE-related cases was used to derive 101 codes describing what went wrong, 67 codes describing reasons why errors occurred, 73 codes describing potential prevention strategies and 21 codes describing recurring error scenarios. Ability to enter these erroneous order scenarios was tested on 13 CPOE systems at 16 sites. Overall, 298 (79.5%) of the erroneous orders were able to be entered including 100 (28.0%) being 'easily' placed, another 101 (28.3%) with only minor workarounds and no warnings.
  
  
  CONCLUSIONS
  Medication error reports provide valuable information for understanding CPOE-related errors. Reports were useful for developing taxonomy and identifying recurring errors to which current CPOE systems are vulnerable. Enhanced monitoring, reporting and testing of CPOE systems are important to improve CPOE safety.
authors.affiliation: Brigham and Women's Hospital Division of General Medicine and Primary Care, Boston, Massachusetts, USA Harvard School of Medicine, Boston, Massachusetts, USA.
authors.forename: G D
authors.initials: GD
authors.lastname: Schiff
authors.affiliation: Brigham and Women's Hospital Division of General Medicine and Primary Care, Boston, Massachusetts, USA MCPHS University, Boston, Massachusetts, USA.
authors.forename: M G
authors.initials: MG
authors.lastname: Amato
authors.affiliation: Brigham and Women's Hospital Division of General Medicine and Primary Care, Boston, Massachusetts, USA Harvard School of Medicine, Boston, Massachusetts, USA McGill University, Montreal, Quebec, Canada.
authors.forename: T
authors.initials: T
authors.lastname: Eguale
authors.affiliation: Brigham and Women's Hospital Division of General Medicine and Primary Care, Boston, Massachusetts, USA.
authors.forename: J J
authors.initials: JJ
authors.lastname: Boehne
authors.affiliation: Brigham and Women's Hospital Division of General Medicine and Primary Care, Boston, Massachusetts, USA Harvard School of Medicine, Boston, Massachusetts, USA.
authors.forename: A
authors.initials: A
authors.lastname: Wright
authors.affiliation: University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: R
authors.initials: R
authors.lastname: Koppel
authors.affiliation: Quantros, San Francisco, California, USA.
authors.forename: A H
authors.initials: AH
authors.lastname: Rashidee
authors.affiliation: MetroHealth Center for HealthCare Research and Policy, Cleveland, Ohio, USA.
authors.forename: R B
authors.initials: RB
authors.lastname: Elson
authors.affiliation: Baylor College of Medicine, Houston, Texas, USA.
authors.forename: D L
authors.initials: DL
authors.lastname: Whitney
authors.affiliation: Brigham and Women's Hospital Division of General Medicine and Primary Care, Boston, Massachusetts, USA.
authors.forename: T-T
authors.initials: TT
authors.lastname: Thach
authors.affiliation: Brigham and Women's Hospital Division of General Medicine and Primary Care, Boston, Massachusetts, USA Harvard School of Medicine, Boston, Massachusetts, USA Harvard School of Public Health, Boston, Massachusetts, USA.
authors.forename: D W
authors.initials: DW
authors.lastname: Bates
authors.affiliation: Brigham and Women's Hospital Division of General Medicine and Primary Care, Boston, Massachusetts, USA MCPHS University, Boston, Massachusetts, USA.
authors.forename: A C
authors.initials: AC
authors.lastname: Seger
mesh_terms: D016208:Databases, Factual; D055695:Electronic Prescribing; D006801:Humans; D050316:Medical Order Entry Systems; D008508:Medication Errors / Q000706:statistics & numerical data*; D010820:Physicians; D014481:United States
keywords: Decision support, computerized; Human error; Information technology; Medication safety; Patient safety