AHRQ Patient Safety Network

The Collection > Computerized Provider Order Entry (CPOE)

PATIENT SAFETY PRIMERS
Computerized Provider Order Entry

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Safety Target

•Device-related Complications (5)

•Diagnostic Errors (3)

•Identification Errors (7)

•Discontinuities, Gaps, and Hand-Off Problems (16)

•Medication Safety (276)

•Medical Complications (9)

•Nonsurgical Procedural Complications (1)

•Surgical Complications (7)

•Transfusion Complications (3)

•Psychological and Social Complications (3)

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•Asia (5)

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•Clinical Guideline (1)

•Journal Article (281)

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•Newspaper/Magazine Article (31)

•Press Release/Announcement (1)

•Special or Theme Issue (3)

•Tools/Toolkit (1)

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Error Types

•Epidemiology of Errors and Adverse Events (90)

•Active Errors (60)

•Latent Errors (20)

•Near Miss (3)

Approach to Improving Safety
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Computerized Provider Order Entry (CPOE)

Clinical Areas

•Medicine (198)

•Nursing (15)

•Pharmacy (115)

Target Audience

•Health Care Providers (227)

•Health Care Executives and Administrators (253)

•Non-Health Care Professionals (211)

•Patients (12)

Setting of Care

•Hospitals (206)

•Psychiatric Facilities (1)

•Residential Facilities (7)

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1 - 20 of 339

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REVIEW

The business case for patient safety.

Hwang RW, Herndon JH. Clin Orthop Relat Res. 2007;457:21-34.

REVIEW

Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems.

Radley DC, Wasserman MR, Olsho LE, Shoemaker SJ, Spranca MD, Bradshaw B. J Am Med Inform Assoc. 2013;20:470-476.

ORGANIZATIONAL POLICY/GUIDELINES

ACOG Committee opinion #531: improving medication safety.

ACOG Committee on Patient Safety and Quality Improvement of American College of Obstetricians-Gynecologists. Obstet Gynecol. 2012;120:406-410.

REVIEW

The National Quality Forum safe practice standard for computerized physician order entry: updating a critical patient safety practice.

Kilbridge PM, Classen D, Bates DW, Denham CR. J Patient Saf. 2006;2:183-190.

REVIEW

E-prescribing: a focused review and new approach to addressing safety in pharmacies and primary care.

Odukoya OK, Chui MA. Res Social Adm Pharm. 2012 Oct 10; [Epub ahead of print].

AUDIOVISUAL

Health agency: drug errors still common.

Knox R. "All Things Considered." National Public Radio. July 20, 2006.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors: a year in review.

Institute for Safe Medication Practices. Pharmacy Practice News. October 2011:7-14.

STUDY

Relationship between medication event rates and the Leapfrog computerized physician order entry evaluation tool.

Leung AA, Keohane C, Lipsitz S, et al. J Am Med Inform Assoc. 2013 Apr 18; [Epub ahead of print].

COMMENTARY

Lessons from "unexpected increased mortality after implementation of a commercially sold computerized physician order entry system."

Sittig DF, Ash JS, Zhang J, Osheroff JA, Shabot MM. Pediatrics. 2006;118:797-801.

STUDY

Medication errors and adverse drug events in pediatric inpatients.

Kaushal R, Bates DW, Landrigan C, et al. JAMA. 2001;285:2114-2120.

STUDY

Decision support for sensible dosing in electronic prescribing systems.

Coleman JJ, Nwulu U, Ferner RE. J Clin Pharm Ther. 2012;37:415-419.

COMMENTARY

ISMP medication error report analysis.

Smetzer JL, Cohen MR. Hosp Pharm. 2008;43:869-872.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing errors relating to commonly used anticoagulants.

Sentinel Event Alert. September 24, 2008;(41):1-4.

STUDY

Medication errors related to computerized order entry for children.

Walsh KE, Adams WG, Bauchner H, et al. Pediatrics. 2006;118:1872-1879.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2007;42:12-13, 36.

AWARD RECIPIENT

An interview with Lucian Leape.

Leape LL. Jt Comm J Qual Saf. 2004;30:653-658.

STUDY

Impact of a pharmacotherapy alerting system on medication errors.

Natali BJ, Varkey AC, Garey KW, Liebl M. Am J Health Syst Pharm. 2013;70:48-52.

STUDY

Prescribers' responses to alerts during medication ordering in the long term care setting.

Judge J, Field TS, DeFlorio M, et al. J Am Med Inform Assoc. 2006;13:385-390.

NEWSPAPER/MAGAZINE ARTICLE

ISMP updates its list of drug name pairs with Tall man letters.

ISMP Medication Safety Alert! Acute Care Edition. November 18, 2010;15:1-3.

COMMENTARY classic

Defining health information technology–related errors: new developments since To Err Is Human.

Sittig DF, Singh H. Arch Intern Med. 2011;171:1281-1284.

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