title: The vulnerabilities of computerized physician order entry systems: a qualitative study.
abstract: OBJECTIVE
  To test the vulnerabilities of a wide range of computerized physician order entry (CPOE) systems to different types of medication errors, and develop a more comprehensive qualitative understanding of how their design could be improved.
  
  
  METHODS
  The authors reviewed a random sample of 63,040 medication error reports from the US Pharmacopeia (USP) MEDMARX reporting system where CPOE systems were considered a "contributing factor" to errors and flagged test scenarios that could be tested in current CPOE systems. Testers entered these orders in 13 commercial and homegrown CPOE systems across 16 different sites in the United States and Canada, using both usual practice and where-needed workarounds. Overarching themes relevant to interface design and usability/workflow issues were identified.
  
  
  RESULTS
  CPOE systems often failed to detect and prevent important medication errors. Generation of electronic alert warnings varied widely between systems, and depended on a number of factors, including how the order information was entered. Alerts were often confusing, with unrelated warnings appearing on the same screen as those more relevant to the current erroneous entry. Dangerous drug-drug interaction warnings were displayed only after the order was placed rather than at the time of ordering. Testers illustrated various workarounds that allowed them to enter these erroneous orders.
  
  
  CONCLUSIONS
  The authors found high variability in ordering approaches between different CPOE systems, with major deficiencies identified in some systems. It is important that developers reflect on these findings and build in safeguards to ensure safer prescribing for patients.
authors.affiliation: Division of Pharmacy, School of Medicine, Pharmacy and Health, Durham University, Durham, UK. The Center for Patient Safety Research and Practice, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: Sarah P
authors.initials: SP
authors.lastname: Slight
authors.affiliation: The Center for Patient Safety Research and Practice, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA. Department of Pharmacy Practice, MCPHS University, Boston, MA, USA.
authors.forename: Tewodros
authors.initials: T
authors.lastname: Eguale
authors.affiliation: The Center for Patient Safety Research and Practice, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA. Department of Pharmacy Practice, MCPHS University, Boston, MA, USA.
authors.forename: Mary G
authors.initials: MG
authors.lastname: Amato
authors.affiliation: Department of Pharmacy Practice, MCPHS University, Boston, MA, USA.
authors.forename: Andrew C
authors.initials: AC
authors.lastname: Seger
authors.affiliation: Baylor College of Medicine, Houston, TX, USA.
authors.forename: Diana L
authors.initials: DL
authors.lastname: Whitney
authors.affiliation: The Center for Patient Safety Research and Practice, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA. Harvard Medical School, 250 Longwood Ave, Boston, MA, USA. Harvard School of Public Health, 677 Huntington Avenue, Boston, MA, USA.
authors.forename: David W
authors.initials: DW
authors.lastname: Bates
authors.affiliation: The Center for Patient Safety Research and Practice, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA. Harvard Medical School, 250 Longwood Ave, Boston, MA, USA. gschiff@partners.org.
authors.forename: Gordon D
authors.initials: GD
authors.lastname: Schiff
mesh_terms: D002170:Canada; D050316:Medical Order Entry Systems / Q000592:standards / Q000706:statistics & numerical data; D008508:Medication Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D014481:United States
keywords: alerts; clinical decision support; electronic prescribing; medication errors; patient safety; workarounds