Study Commissioned to Investigate CPOE-Related Errors

The National Patient Safety Foundation (NPSF) has awarded a research grant to the Center for Patient Safety Research and Practice at the Brigham and Women’s Hospital and Harvard Medical School to research errors associated with CPOE, as well as the vulnerability of leading CPOE systems.

Quantros (the company that manages MEDMARX, a Web-based solution that collects anonymous reports of medication errors) will partner with the Center on the year-long project. Quantros is also partnering with the Institute for Safe Medication Practices (ISMP) to help support project reporting and analysis.

Researchers from the Center for Patient Safety Research and the Quantros Patient Safety Center, a federally certified Patient Safety Organization, will investigate about 200,000 MEDMARX records where CPOE was listed as a contributing factor. The research will focus on such topics as:

• Creating descriptive statistics to analyze the drugs, dosing issues, prescribing and dispensing issues, outcomes and other contributing factors identified by the reporters of CPOE-related errors
• Extracting insights from report narratives to better understand the nature and mechanism of the reported CPOE-related errors and how better designed systems might have prevented them, and
• Developing and testing a new classification for CPOE-related errors and process failure modes to collect more useful data.