Skip Navigation
The Collection >
Mixed results in the safety performance of computerized physician order entry. Classic icon
Metzger J, Welebob E, Bates DW, Lipsitz S, Classen DC. Health Aff (Millwood). 2010;29:655-663.

Computerized provider order entry (CPOE) has provided significant safety benefits in research studies, especially when combined with clinical decision support to prevent common prescribing errors. However, CPOE's "real-world" performance has been mixed, with high-profile studies documenting a variety of unintended consequences. This AHRQ-funded study used simulated patient records to evaluate the ability of eight commercial CPOE modules to prevent medication errors. The overall results were disappointing, as CPOE failed to prevent many medication errors—including fully half of potentially fatal errors, which are considered never events. The individual CPOE products varied significantly in their ability to detect potential errors. Some hospitals did achieve superior performance, which the authors ascribe to greater experience with CPOE and implementation of more advanced decision support tools. Another recent article found that reminders within CPOE systems resulted in only small improvements in adherence to recommended care processes. Taken together, these studies imply that CPOE implementation may not result in large immediate effects on safety and quality in typical practice settings.

PubMed citation icon indicating hyperlink to external website
Available at icon indicating hyperlink to external website
white box
Related Resources
COMMENTARY
In Conversation with…Eric G. Poon, MD, MPH
AHRQ WebM&M [serial online]. September 2008.
STUDY
Impact of health information technology on detection of potential adverse drug events at the ordering stage.
Roberts LL, Ward MM, Brokel JM, Wakefield DS, Crandall DK, Conlon P. Am J Health Syst Pharm. 2010;67:1838-1846.
STUDY
Impact of electronic prescribing in a hospital setting: a process-focused evaluation. 
Cunningham TR, Geller ES, Clarke SW. Int J Med Inform. 2008;77:546-554.
BOOK/REPORT
Inpatient Computerized Provider Order Entry: Findings from the AHRQ Health IT Portfolio.
Dixon BE, Zafar A, for AHRQ National Resource Center for Health IT. Rockville, MD: Agency for Healthcare Research and Quality; January 2009. AHRQ Publication No. 09-0031-EF.
View all related resources...
white box
Download: Adobe Reader   email icon Email
tan box
white box