CPOE systems, on average, missed one half of routine medication order errors and a third of potentially fatal order errors during a study The Leapfrog Group conducted of 214 hospitals using its Web-based simulation tool.
Leapfrog CEO Leah Binder characterized the results as “disturbing.”
On a positive note, of the 102 hospitals that retook the test following a six-month interval, 94 percent showed some level of improvement. During the time between tests, hospitals adjusted their systems and protocols, said Binder.
“I visited four of the organization that retook the test and asked them about their improvement process,” she said. “They convened pharmacy and the medical staff to go through and reconsider some of the automatic alerts and system features that created the mistakes.”
Leapfrog provided the organizations with a detailed report on the errors so they could be studied and addressed. Added Barbara Rudolph, senior science director, Leapfrog, “Sometimes it was found certain medications should have been alerted at a higher level, or they were not coming directly back to the doctors at the time they were entering the order.”
Two of the four organizations that Binder visited worked with their CPOE vendors on the adjustments. “That’s certainly something I would expect them to do,” she added.
A key finding of the study, according to David Knowlton — president & CEO of the New Jersey Health Care Quality Institute and Chair of Leapfrog’s Board of Directors — was that CPOE systems require customization and continuous monitoring to be effective. “These systems are not plug and play,” he explained, calling on the federal government to institute monitoring requirements as part of the HITECH Meaningful Use program.
Leapfrog’s formal recommendation to the government and industry reads: “For the sake of safe patient care, hospitals must test and monitor their CPOE systems on an ongoing basis to achieve true meaningful use. In addition, vendors and hospitals must collaborate more closely during the pre-implementation and implementation phases to ensure that best practices are shared and followed.”
Added Binder, “The complexity of CPOE has to be honored.” CIOs, she said, were at a disadvantage because they lacked a window into the effectiveness of their CPOE systems, something she said Leapfrog’s tool could address. She also encouraged the industry to develop a shared repository of CPOE best practices which could be continually updated with new lessons learned. “Every CIO at every hospital in the country should not have to reinvent this wheel,” she added.
Additional Study Details: The simulations were conducted from June 2008 to January 2010.
Summary of Results
Between June 2008 and January 2010, 214 hospitals from across the U.S. completed Leapfrog’s CPOE evaluation tool. The 214 hospitals include urban, rural, and pediatric hospitals.
Each adult hospital was given a scenario of 10 test patients and 50 medication orders; pediatric hospitals received 10 test patients and 51 medication orders. Each of the orders in the test scenario would result in an adverse drug event, and some of the test orders would result in a potentially fatal medication error.
Hospitals receive medication orders in several categories, including:
- Therapeutic Duplication
- Medication with therapeutic overlap with another new or active order; may be same drug, within drug class, or involve components of combination products. Example: Codeine AND Tylenol #3.
- Single and Cumulative Dose Limits
- Medication with a specified dose that exceeds recommended dose ranges or that will result in a cumulative dose that exceeds recommended ranges. Example: Ten-fold excess dose of Methotrexate.
- Allergies and Cross Allergies
- Medication for which patient allergy has been documented or allergy to other drug in same category has been documented. Example: Penicillin prescribed for patient with documented Penicillin allergy.
- Contraindicated Route of Administration
- Medication order with an incorrectly specified route of administration (e.g., oral, intramuscular, intravenous) that is not appropriate for the identified medication. Example: Tylenol to be administered intravenously.
- Drug-Diagnosis Interactions
- Medication either contraindicated based on patient diagnosis or diagnosis affects appropriate dosing. Example: Nonspecific beta blocker in patient with asthma.
- Contraindications/Dose Limits Based on Age and Weight
- Medication either contraindicated for this patient based on age and weight or for which age and weight must be considered in appropriate dosing. Example: Adult dose of antibiotic in a newborn.
- Contraindications/Dose Limits Based on Lab Studies
- Medication either contraindicated for this patient based on laboratory studies or for which relevant laboratory results must be considered in appropriate dosing. Example: Normal adult dose regimen of renally eliminated medication in patient with elevated creatinine.
- Contraindications/Dose Limits Based on Radiology Studies
- Medication contraindicated for this patient based on interaction with contrast medium in recent or ordered radiology study. Example: Medication prescribed known to interact with iodine to be used as contrast medium in ordered head CT exam.
Of the 214 hospitals analyzed for the report, 187 hospitals completed an adult CPOE test and 37 hospitals completed a pediatric test. Ten hospitals completed both an adult and pediatric test resulting in 224 total CPOE tests and 10,447 total medication orders processed through hospital CPOE systems.