Technology can cause medication errors, study finds

One problem with computerized physician order entry systems, researchers say, is that systems aren't created with physician workflow in mind.

By Tyler Chin — Posted March 28, 2005

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As the cry grows louder to use information technology to cure the ills of the health care industry, a new study finds computers might not be the right prescription for communication problems.

In a study published in the March 9 Journal of the American Medical Association, researchers concluded that computerized physician order entry systems -- widely touted as tools to reduce medication errors and improve patient safety -- facilitated 22 types of medication errors at the Hospital University of Pennsylvania, a teaching hospital that is part of the University of Pennsylvania Health System and one of the earliest health systems in the country to use the technology.

A two-year examination of the TDS 7000 order entry system from Eclipsys Corp., Boca Raton, Fla., that the hospital used between 1997 and 2004, found that 45% (10 out of 22) of those errors were caused by the technology itself and the lack of connectivity between it and other departmental information systems at the hospital.

The remainder were caused by what the researchers described as "human-machine interface flaws," or the failure of the technology to reflect how doctors and organizations work.

"I'm not opposed to CPOE," said Ross Koppel, PhD, a sociologist at the Center for Clinical Epidemiology and Biostatistics at the University of Pennsylvania School of Medicine, and the principal author of the study, which was augmented by a JAMA editorial supporting its conclusions. "I think CPOE offers many advantages over a paper-based system, but using CPOE stupidly just enhances the errors that are already inherent in any system."

Based on one-on-one interviews, focus groups, and "shadowing" of house staff and nurses using the system, "stupid" uses of an order entry system include using it in a way "that is not integrated with the way the hospital actually does work, using it where you're not constantly being vigilant about the way it's used and the way information flows within an organization," Dr. Koppel said.

The study's findings will likely resonate among many physicians, especially those in small and medium-sized practices. A majority of those physicians have not yet adopted electronic medical records software for several reasons, including their belief that EMR technology is poorly designed and doesn't reflect how they work.

The AMA has endorsed the use of information technology, but has policy against physicians being forced to buy it or use it.

"Too often we ... ask doctors and hospital personnel to somehow conform to the system. ... That is stupid because the system is a series of lines of code written by programmers, and they can make it more responsive to the practice of better medicine," Dr. Koppel said.

Swift rebuttal

President Bush has stated he wants to see electronic medical records fully in place in 10 years. Corporate organizations, such as the Leapfrog Group, advocate information technology as a way to reduce errors and reduce health care costs.

Concerned that doctors and hospitals might seize on the study as reason to delay implementing clinical information technology, several parties were quick to offer a rebuttal of the JAMA study, titled "Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors."

Their criticisms centered around the fact that researchers studied a system that was first developed in the late 1960s and only studied its use at a single site that no longer uses the system. Eclipsys stopped selling the TDS 7000 system in the late 1990s, though it continues to provide support for the system because many hospitals around the country are still using it.

The University of Pennsylvania researchers based their conclusion "on a first-generation system deployed in a single setting" that Eclipsys no longer sells to hospitals, the company said in a press release. The successor to the TDS system -- Sunrise Clinical Manager, which the Hospital of the University of Pennsylvania installed in 2004 -- addresses many of the shortcomings the researchers uncovered, Eclipsys said.

"One would have to view this as an embryonic early version of CPOE," so there were bound to be lessons learned by the early adopters and by the companies selling CPOE, said David Classen, MD, vice president at First Consulting Group.

Another flaw of the study is that "the researchers did not measure whether or not CPOE increased or decreased error rates," said David Bates, MD, chief of the division of internal medicine at Brigham and Women's Hospital in Boston, whose research has found that order entry reduced medication errors by up to 80%.

Dr. Koppel noted that he and the researchers had fully disclosed the limitations critics pointed to in their study.

"Well, there is validity to the fact that it's an old system and that many of the newer systems don't have those level of problems [we found]. That's entirely true. But does that mean that the new systems haven't introduced new kinds of errors? The answer is, sure they have," Dr. Koppel said, noting that he has observed the same dynamics in play at hospitals that have implemented newer systems.

"I don't want to suggest that newer systems don't improve. They do, but they continue to be problematic exactly for the same reasons," Dr. Koppel said. "All systems are going to create changes and require extraordinary integration [of technology and workflow]. No matter how good the system, constant vigilance, constant analysis and constant tweaking are required to make them function effectively."

Proponents of CPOE and electronic medical records acknowledged that point.

"The thing I took away from the study is that introducing a new computer system can create errors as well as reduce their frequency, and that it's very important to do quality control with any new technology [after you implement it]," Dr. Bates said. "I think it's important to understand what [the study] shows and what it doesn't show."

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Unintended consequences

Researchers at the University of Pennsylvania found that computerized physician order entry systems facilitated 22 types of errors due to a combination of software design, lack of integration with other clinical systems and failure to reflect how clinicians work. Examples of those errors include:

  • Ordering wrong medication dosage because pharmacy purchasing dosage decisions were misread as clinical guidelines.
  • Ordering new or modifying existing prescriptions without canceling old orders because viewing a single patient's medications could require looking at as many as 20 screens. The fragmented CPOE displays also led to delays of several hours in canceling medications.
  • Causing gaps in antibiotic therapy because of a lack of coordination among information systems.
  • Prescribing a drug for the wrong patient because names of patient files and drugs were listed close together in small type and the patients' names didn't appear on all screens.
  • Ordering prescriptions for the wrong patient or not getting intended medication to patients because the previous physician had failed to log out of the computer.
  • Losing data and delaying medication orders because the CPOE system crashed or was down for maintenance.

Source: "Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors," JAMA, March 9

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External links

"Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors," Journal of the American Medical Association, March 9 (link)

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