CPOE Systems Miss Half of Drug Errors, Says Report

Health IT could inadvertently result in harm to patients without proper monitoring, according to a new report issued The Leapfrog Group, which showed that computerized provider order entry (CPOE) systems can miss half of the routine medication orders issued in the hospital setting—and a third of the potentially fatal orders.

Using a Web‐based simulation tool, 214 hospitals tested their CPOE systems for their ability to catch common medication errors, including errors those that could lead to fatalities, between June 2008 and January 2010.

The results are eye-opening, according to Leapfrog CEO Leah Binder. “Although this is a simulation using fictitious patients and medication orders, it should be a red flag for every hospital and information technology company in America. The belief that simply buying and installing health information technology will automatically lead to safer and better care is a myth. Hospitals and vendors must continue to work together over time to ensure the effectiveness and efficiency of CPOE.”

The report calls on federal officials to act quickly by building oversight requirements into healthcare IT regulations now being finalized in Washington. It also identifies actions that hospitals and CPOE technology companies should take to assure the quality and safety of these systems.

“The federal government must exercise leadership here, because lives are at stake,” said Leapfrog Chairman David Knowlton, president and CEO of the New Jersey Health Care Quality Institute. “As they define meaningful use as a standard for federal funding assistance to hospitals, they must require more than just adoption and implementation. The government must insist that hospitals and IT companies do continuous monitoring and improvement.”

According to Leapfrog, 26% of the 1,244 hospitals that completed the Leapfrog Hospital Survey in 2009 report having a CPOE system in at least one inpatient department.