Impact of Computerized Physician Order Entry on Medication Error Rate
Winifred Masterson Burke Rehabilitation Hospital
White Plains, New York, USA
Team
Tom Grandville, MS, PharmD, Director of Pharmacy Services
Ken Kupetsky, CIO
Annmarie Molinari, RPh, Staff Pharmacist
Stephanie Campbell, BS, RN, Assistant Director of Nursing
Aim
To decrease the medication error rate by 50 percent by implementing a commercially available Computerized Physician Order Entry (CPOE) system.
Measures
Medication error rates for 12 months prior and 12 months post CPOE implementation
Changes
The total number of medication errors were recorded monthly for 12 months prior to and 12 months after CPOE implementation. These monthly errors were reviewed to determine whether or not CPOE would decrease the error rate by at least 50 percent as suggested by the Leapfrog Group for Patient Safety.
- Reduction in medication error rate revealed after Computerized Physician Order Entry implementation
- Improvement in medication error categories
- Conducted clinician training before, during, and after CPOE implementation
- Eliminated the error types "illegibility" and "transcription errors"
- Eliminated unauthorized abbreviations with CPOE use
Results
Summary of Results / Lessons Learned / Next Steps
A reduction in the medication error rate of just over 50 percent was realized after implementing a CPOE system. This project summarizes the experiences of a 150-bed specialty hospital that implemented a commercially available CPOE system.
For those wishing to implement CPOE in their facilities and are unable to develop a system in-house, we offer the following suggestions with regard to implementing commercial systems:
- Develop a close working relationship with all clinical staff who will be affected by CPOE.
- IT Support is essential throughout the entire process.
- Be aware that both human and financial resources may be strained.
- When reviewing vendors, determine which one offers the highest degree of customization.
- Systems with good Clinical Decision Support (CDS) Tools will often yield the best outcomes.
- Monitor system routinely to ensure it continues to perform as designed.
This study has shown that there can be a reduction in medication error rate even with a commercially available CPOE system. However, the current generation of commercially available systems may not yet be customizable enough to maximize benefits. Vendors are currently developing methods for user customization which should greatly enhance patient safety.
Contact Information
Tom Grandville, MS, PharmD, Director of Pharmacy Services
Burke Rehabilitation Hospital
tgrandvi@burke,org
[Storyboard presentation at IHI's National Forum, December 2005]
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