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Patient Safety

Wednesday, June 30, 2010

Report Urges Hospitals To Test Error Detection in CPOE Tools

Although computerized physician order entry systems have been touted for their ability to detect potential medication errors, hospitals and IT vendors should examine them closely to ensure they are properly detecting such errors, according to a Leapfrog Group report released Wednesday, Modern Healthcare reports.

The health care quality group issued the warning based on the findings of a study conducted between June 2008 and January 2010. For the study, Leapfrog Group invited 214 hospitals to use the group's Web-based simulation tool to evaluate their CPOE systems (McKinney, Modern Healthcare, 6/30).

The CPOE evaluation was a part of Leapfrog Group's annual hospital survey, which found that 26% of the 1,244 hospital respondents had a CPOE system in at least one inpatient department.

Study Findings

The simulations found that the hospitals' CPOE systems on average failed to detect half of the routine medication orders and one-third of potentially fatal orders.

However, the study also found that detection rates improved at nearly all hospitals after they recalibrated their CPOE systems and ran the simulation a second time (Monegain, Healthcare IT News, 6/30).

Leapfrog Group CEO Leah Binder said, "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," adding, "The belief that simply buying and installing health information technology will automatically lead to safer and better care is a myth" (Modern Healthcare, 6/30).

Recommendations

In the report, Leapfrog Group offered several recommendations to ensure that CPOE systems can detect medication errors. The group called for:

  • Including a testing and monitoring component as part of the requirements for "meaningful use" of health IT;
  • Developing an easier and more transparent way to share information about best practices for health IT adoption; and
  • Promoting widespread CPOE adoption to spur advancements in the technology over time (Healthcare IT News, 6/30).



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