Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing...

Area of Science:

• Health Informatics
• Patient Safety
• Medical Error Analysis

Background:

• Computerised provider order entry (CPOE) is widely adopted to reduce medication errors.
• However, CPOE systems can also be a source of new or contributing medication errors.

Purpose of the Study:

• To analyze medication error reports where CPOE was a contributing factor.
• To develop use cases from these reports to test CPOE system vulnerabilities.

Main Methods:

• Reviewed 10,060 CPOE-related medication errors from the MEDMARX system (2003-2010).
• Developed a taxonomy of CPOE errors, reasons, prevention strategies, and recurring scenarios.
• Tested the vulnerability of 13 leading CPOE systems using these error scenarios.

Main Results:

• Over 63,000 CPOE-related errors were reported.
• Identified 101 error types, 67 reasons, 73 prevention strategies, and 21 error scenarios.
• 79.5% of erroneous orders could be entered into CPOE systems, with 28% entered easily.

Conclusions:

• Medication error reports are crucial for understanding CPOE-related errors.
• Current CPOE systems exhibit vulnerabilities to recurring error scenarios.
• Enhanced monitoring, reporting, and testing are vital for improving CPOE safety.