February 2004 Bulletin

Patient safety tip from Dr. Herndon -- Are computerized physician order entry systems (CPOE) ready for prime time?

The AAOS Board of Directors recently approved an “Advisory Statement on the Prevention of Medication Errors” recommended by the Patient Safety Committee. It states:

The AAOS recommends the following tools when prescribing, transcribing, dispensing, administering and monitoring patient medications: computerized physician order entry (CPOE), computerized decision support systems (CDSS), computerized monitoring of adverse drug events, pharmacist assisted rounds, high-risk drug protocols, and verbal order verification. These tools have significantly reduced medication errors, improved quality of care and patient management capabilities, increased reimbursement, and have decreased billing time.

Electronic prescribing reduces medication errors, still the number one error leading to adverse events in medical care. Its use is supported by a recent report by the Institute of Medicine. David Bates, MD, and others have repeatedly demonstrated reductions in serious medication-related errors ranging from 55 percent to 83 percent in hospitals that have implemented CPOE systems.

A recent study in a pediatric critical care unit reported that the use of CPOE reduced the overall medication error rate by 96 percent. Reports from individual hospitals establish similar rates of error reduction. These hospitals also report other benefits: reductions in transcription errors, in medication-order processing time (up to 64 percent), in turnaround time for radiology results (up to 43 percent), in turnaround time for lab results (up to 25 percent), as well as “improved overall work flow in areas affected by CPOE.”

Senior citizens are at even greater risk of hospital medication errors, according to the United States Pharmacopeia (USP): “A majority (55 percent) of fatal hospital medication errors reported involved seniors aged 65 or older. Ten percent of prescribing errors to seniors were harmful.” To date there is little information on medication errors in outpatient settings, but preliminary data suggests rates similar to those of inpatients.

Admittedly, an in-hospital CPOE system is expensive — $5 million to $10 million to purchase and implement—and expense remains the major obstacle to widespread use. Numerous other barriers exist including: physician resistance; lack of integration with practice management systems; financial costs to physicians, especially in small practices; lack of standards for representation of key clinical data and the overall tendency by care providers and policy makers “to see information technology as relatively unimportant for either research efforts or incorporation into medical practice.”

Few hospitals have adopted CPOE systems for physicians—less than 10 percent—but 30 percent are currently evaluating or implementing such systems. The Leapfrog Group, a coalition of some of the nation’s largest employers, has identified CPOE “as one of three changes that they believe would most improve patient safety.” In Massachusetts, Tufts Health Plan recently announced a plan to spend “$3 million to roll out e-prescribing technology (Blackberry and Pocket PC handheld devices) to the 3,400 highest prescribers in their networks,” including discounts on wireless service or high-speed Internet access.

Efforts to encourage physicians to use CPOE in both the outpatient and inpatient arenas will continue. Efforts to include pharmacists on rounds, to use bar codes to track patients’ drugs, to establish verbal order verification protocols and high-risk drug protocols and to use CDSS will increase.
Each of these initiatives aims to reduce medical errors and each of us should encourage and support their use, especially CPOE and e-prescribing in our offices, ambulatory surgical centers and hospitals. By doing so, we can again turn the wrench to reduce medical errors and improve the safety of our patients.

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