• Chunliu Zhan, Rodney W Hicks, Christopher M Blanchette, Margaret A Keyes, and Diane D Cousins.
• Agency for Healthcare Research and Quality (AHRQ), Rockville, MD 20850, USA. czhan@ahrq.gov
• Am J Health Syst Pharm. 2006 Feb 15; 63 (4): 353-8.

PurposeThe potential benefits and problems associated with computerized prescriber-order-entry (CPOE) systems were studied.MethodsA national voluntary medication error-reporting database, Medmarx, was used to compare facilities that had CPOE with those that did not have CPOE. The characteristics of medication errors reportedly caused by CPOE were explored, and the text descriptions of these errors were qualitatively analyzed.ResultsFacilities with CPOE reported fewer inpatient medication errors and more outpatient medication errors than facilities without CPOE, but the statistical significance of these differences could not be determined. Facilities with CPOE less frequently reported medication errors that reached patients (p < 0.01) or harmed patients (p < 0.01). More than 7000 CPOE-related medication errors were reported over seven months in 2003, and about 0.1% of them resulted in harm or adverse events. The most common CPOE errors were dosing errors (i.e., wrong dose, wrong dosage form, or extra dose). Both quantitative and qualitative analyses indicate that CPOE could lead to medication errors not only because of faulty computer interface, mis-communication with other systems, and lack of adequate decision support but also because of common human errors such as knowledge deficit, distractions, inexperience, and typing errors.ConclusionA national, voluntary medication error-reporting database cannot be used to determine the effectiveness of a CPOE system in reducing medication errors because of the variability in the number of reports from different institutions. However, it may provide valuable information on the specific types of errors related to CPOE systems.

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