Medical Error: How to Reduce It

Electronic medicine takes many forms. Information at the point of care can radically reduce medical error, the third leading cause of death in the United States. The largest component of medical error is caused by medication error, by itself the fourth leading cause of death. Computer Physician Order Entry (CPOE) can reduce medication error by over 95% in pediatric critical care units. Currently, only about 6% of healthcare institutions use these systems in the U.S. and only a small fraction of those have more than 50% of physicians actually using CPOE.

PEDIATRICS Vol. 113 No. 1 January 2004, pp. 59-63

Computerized Physician Order Entry and Medication Errors in a Pediatric Critical Care Unit

Amy L. Potts, PharmD, Frederick E. Barr, MD, MSCI, David F. Gregory, PharmD, BCPS, Lorianne Wright, PharmD and Neal R. Patel, MD, MPH

Objective. Medication errors are a major concern of health care professionals and medical institutions, especially errors involving children. Studies in adults have shown that computerized physician order entry (CPOE) systems reduce medication errors and adverse drug events (ADEs). The effect of CPOE implementation in a pediatric population has not been reported. The objective of this study was to evaluate the impact of CPOE on the frequency of errors in the medication ordering process in a pediatric critical care unit (PCCU).

Methods. A prospective trial was conducted of 514 pediatric patients who were admitted to a 20-bed PCCU in a children’s hospital before and after implementation of CPOE. Medication errors were identified after review of all orders during the study period and then further classified as potential ADEs, medication prescribing errors (MPE), and rule violations (RV).

Results. A total of 13 828 medication orders were reviewed. Before implementation, potential ADEs occurred at a rate of 2.2 per 100 orders, MPEs at a rate of 30.1 per 100 orders, and RVs at a rate of 6.8 per 100 orders. After implementation, the rate of potential ADEs was reduced to 1.3 per 100 orders, MPEs to 0.2 per 100 orders, and RVs to 0.1 per 100 orders. The overall error reduction was 95.9%. Potential ADEs were reduced by 40.9%, and MPEs and RVs were reduced by 99.4% and 97.9%, respectively.

Conclusions. The implementation of CPOE resulted in almost a complete elimination of MPEs and RVs and a significant but less dramatic effect on potential ADEs.

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