Computerized prescriber order entry-related patient safety reports: analysis of 2522 medication errors.
To examine medication errors potentially related to computerized prescriber order entry (CPOE) and refine a previously published taxonomy to classify them.



We reviewed all patient safety medication reports that occurred in the medication ordering phase from 6 sites participating in a United States Food and Drug Administration-sponsored project examining CPOE safety. Two pharmacists independently reviewed each report to confirm whether the error occurred in the ordering/prescribing phase and was related to CPOE. For those related to CPOE, we assessed whether CPOE facilitated (actively contributed to) the error or failed to prevent the error (did not directly cause it, but optimal systems could have potentially prevented it). A previously developed taxonomy was iteratively refined to classify the reports.



Of 2522 medication error reports, 1308 (51.9%) were related to CPOE. Of these, CPOE facilitated the error in 171 (13.1%) and potentially could have prevented the error in 1137 (86.9%). The most frequent categories of "what happened to the patient" were delays in medication reaching the patient, potentially receiving duplicate drugs, or receiving a higher dose than indicated. The most frequent categories for "what happened in CPOE" included orders not routed to or received at the intended location, wrong dose ordered, and duplicate orders. Variations were seen in the format, categorization, and quality of reports, resulting in error causation being assignable in only 403 instances (31%).



Errors related to CPOE commonly involved transmission errors, erroneous dosing, and duplicate orders. More standardized safety reporting using a common taxonomy could help health care systems and vendors learn and implement prevention strategies.
Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.|MCPHS University, Boston, USA.
Mary G
MG
Amato
Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.
Alejandra
A
Salazar
Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.
Thu-Trang T
TT
Hickman
Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.
Arbor Jl
AJ
Quist
Partners HealthCare, Information Systems, Wellesley, Massachusetts, USA.
Lynn A
LA
Volk
Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.|Harvard Medical School, Boston, USA.
Adam
A
Wright
Partners HealthCare, Information Systems, Wellesley, Massachusetts, USA.
Dustin
D
McEvoy
University of Illinois at Chicago, Chicago, Illinois, USA.
William L
WL
Galanter
University of Pennsylvania, Philadelphia, USA.
Ross
R
Koppel
Atrius Health, Boston, USA.
Beverly
B
Loudin
Columbia University Medical Center, New York, New York, USA.
Jason
J
Adelman
University of Pennsylvania, Philadelphia, USA.
John D
JD
McGreevey
Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA.
David H
DH
Smith
Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.|Partners HealthCare, Information Systems, Wellesley, Massachusetts, USA.|Harvard Medical School, Boston, USA.|Harvard School of Public Health, Boston, USA.
David W
DW
Bates
Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.|Harvard Medical School, Boston, USA.
Gordon D
GD
Schiff
D055695:Electronic Prescribing; D006801:Humans; D050316:Medical Order Entry Systems; D008508:Medication Errors / Q000145:classification*; D061214:Patient Safety
computerized provider order entry; electronic prescribing; health information technology; medication errors; medication safety
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