Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system

Area of Science:

• Pediatric critical care
• Health informatics
• Patient safety

Background:

• The Institute of Medicine and Leapfrog Group spurred adoption of Computerized Physician Order Entry (CPOE) systems to enhance patient safety and reduce medical errors.
• Our institution implemented a commercial CPOE system to improve care for children requiring specialized transport.

Purpose of the Study:

• To evaluate the hypothesis that CPOE implementation leads to decreased mortality in pediatric patients transferred for specialized care.
• To assess the impact of CPOE on mortality rates in critically ill children.

Main Methods:

• Retrospective analysis of demographic, clinical, and mortality data for children admitted via interfacility transport over 18 months.
• Comparison of mortality rates during a 13-month pre-CPOE period versus a 5-month post-CPOE implementation period.
• Rapid, hospital-wide implementation of a CPOE system within a 6-day period.

Main Results:

• Overall mortality rate was 3.86% (75 deaths among 1942 children).
• Mortality significantly increased from 2.80% pre-CPOE to 6.57% post-CPOE implementation.
• Multivariate analysis confirmed CPOE independently associated with increased mortality odds (OR 3.28; 95% CI 1.94-5.55).

Conclusions:

• An unexpected rise in pediatric mortality was observed concurrently with CPOE system implementation.
• While CPOE offers potential benefits, continuous monitoring of mortality effects is crucial, especially for time-sensitive pediatric therapies.
• Institutions should assess mortality alongside medication error rates when implementing CPOE systems.