Computerized physician order entry, a factor in medication errors: descriptive analysis of events in the intensive care unit safety reporting system.

Study

Computerized physician order entry, a factor in medication errors: descriptive analysis of events in the intensive care unit safety reporting system.

September 28, 2005

Thompson DA; Duling L; Holzmueller CG; et al. JCOM. 2(8):407-412

View more articles from the same authors.

In this AHRQ-funded study, the authors analyze a computerized provider order entry (CPOE) system implemented in 18 intensive care units. They determined that although CPOE may prompt a new set of errors when first introduced, hospital leaders should ensure support for training and response to user suggestions to realize CPOE's safety benefits.

Abstract

Related Resources From the Same Author(s)

Development of the ICU safety reporting system.

May 11, 2005

Pediatric safety incidents from an intensive care reporting system.

May 27, 2009

Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel.

November 15, 2006

Maintaining and sustaining the On the CUSP: Stop BSI model in Hawaii.

January 30, 2013

Health Literacy: A Prescription to End Confusion.

March 6, 2005

Developing an adverse event reporting system using administrative data.

March 19, 2008

Implementing and validating a comprehensive unit-based safety program.

May 11, 2005

Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care.

February 20, 2013

A better approach to medical malpractice claims? The University of Michigan experience.

August 5, 2009

Corporate Responsibility and Health Care Quality: A Resource for Health Care Boards of Directors.

July 18, 2007

Sleep and alertness in a duty-hour flexibility trial in internal medicine.

March 13, 2019

Keeping our Promises: Research, Practice, and Policy Issues in Health Care Reliability.

August 16, 2006

ER doctor discusses role in Ebola patient's initial misdiagnosis.

December 17, 2014

Medication Safety: A Guide for Health Care Facilities.

July 20, 2005

Errors in Organizations.

August 1, 2012

How a simple checklist can dramatically reduce medical errors.

December 3, 2008

Learning in Action: A Guide to Putting the Learning Organization to Work.

March 27, 2005

The Design of Everyday Things.

March 27, 2005

Safer Clinical Systems: Evaluation Findings.

February 18, 2015

Errors in Laboratory Medicine and Patient Safety.

June 3, 2009

Assessing the Evidence for Context-Sensitive Effectiveness and Safety of Patient Safety Practices: Developing Criteria.

June 8, 2011

WebM&M Cases

To Resuscitate or Not?

January 1, 2004

Prescribing for the elderly. Part I: Sensitivity of the elderly to adverse drug reactions.

March 27, 2005

Patient-safety and quality initiatives in the intensive-care unit.

April 5, 2006

New Horizons in Patient Safety: Understanding Communication: Case Studies for Physicians.

April 5, 2017

You can't understand something you hide: transparency as a path to improve patient safety.

July 8, 2015

Improving the Emergency Department Discharge Process.

January 7, 2015

How safe do patients feel?

December 14, 2005

Patient Safety.

December 12, 2007

Medical Errors and Patient Safety: A Curriculum Guide for Teaching Medical Students and Family Practice Residents.

March 6, 2005

Intrapersonal and institutional influences on overall perception of radiation safety among radiologic technologists.

April 6, 2022

Association of coworker reports about unprofessional behavior by surgeons with surgical complications in their patients.

July 10, 2019

Diagnostic accuracy of prehospital triage tools for identifying major trauma in elderly injured patients: a systematic review.

May 5, 2021

Report 6: Managing Risk and Minimising Mistakes in Services to Children and Families.

October 5, 2005

Choosing wisely in clinical practice: embracing critical thinking, striving for safer care.

April 6, 2022

Interdisciplinary Perspectives on Medical Error.

January 29, 2014

The next wave of hospital innovation to make patients safer.

August 17, 2016

WISH Patient Safety Forum 2015.

January 13, 2016

From Science to Implementation: AHRQ's Program to Prevent HAIs—Results and Lessons.

November 5, 2014

Frequency of risk factors that potentially increase harm from medications in older adults receiving primary care.

January 23, 2008

Reducing Adverse Drug Events.

March 6, 2005

Engaging patients in the use of real-time electronic clinical data to improve the safety and reliability of their own care.

May 4, 2022

Infection Control in the Intensive Care Unit.

August 25, 2010

Implementing a human factors approach to RCA(2) : tools, processes and strategies.

March 10, 2021

Advances in the Prevention and Control of HAIs.

August 20, 2014

Improving Patient Safety Through Informed Consent for Patients with Limited Health Literacy.

September 28, 2005

Meeting the Challenge of Patient Safety in the Ambulatory Care Setting.

September 2, 2009

Evaluation of postoperative handover using a tool to assess information transfer and teamwork.

May 4, 2011

Implementing Optimal Team-Based Care to Reduce Clinician Burnout.

September 19, 2018

Professional behavior and value erosion: a qualitative study of physicians and the electronic health record.

November 9, 2022

Engagement of leadership in quality improvement initiatives: executive quality improvement survey results.

July 11, 2007

Pediatric Diagnostic Safety: State of the Science and Future Directions.

September 13, 2023

The July Effect in podiatric medicine and surgery residency.

July 14, 2021

Reducing the Risk by Designing a Safer, Shame-free Health Care Environment.

September 26, 2007

Safe healthcare.

March 6, 2005

The 2004 John M. Eisenberg Patient Safety and Quality Awards.

March 6, 2005

Examination of impact of after-hours admissions on hospital resource use, patient outcomes, and costs.

January 11, 2023

An In Depth Investigation into Causes of Prescribing Errors by Foundation Trainees in Relation to Their Medical Education—EQUIP Study.

January 6, 2010

Planning for a pandemic: mitigating risk to radiation therapy service delivery in the COVID-19 era.

July 22, 2020

Association of past and future paid medical malpractice claims.

March 1, 2023

Understanding the "Swiss cheese model" and its application to patient safety.

July 21, 2021

The impact of health care strikes on patient mortality: a systematic review and meta-analysis of observational studies.

November 30, 2022

Patient safety functions of state medical boards in the United States.

April 21, 2021

Perspective: a culture of respect—part 1 and part 2.

June 20, 2012

Medication Safety for Look-alike, Sound-alike Medicines.

November 15, 2023

2022 Updated Results for the AHRQ Surveys on Patient Safety Culture Workplace Safety Supplemental Item Set for Hospitals.

December 7, 2022

Analysis of errors in dictated clinical documents assisted by speech recognition software and professional transcriptionists.

July 25, 2018

STARD 2015 guidelines for reporting diagnostic accuracy studies: explanation and elaboration.

October 14, 2016

Patient safety outcomes under flexible and standard resident duty-hour rules.

March 13, 2019

The Leapfrog Group's CPOE standard and evaluation tool.

July 30, 2008

Overview of the Environmental Scan of Primary Care-Based Effort To Reduce Readmissions.

March 27, 2019

Impact of the COVID-19 pandemic on the experiences of hospitalized patients: a scoping review.

February 22, 2023

Are pathologists self-aware of their diagnostic accuracy? Metacognition and the diagnostic process in pathology.

October 5, 2022

Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration.

January 9, 2019

Environmental Cleaning for the Prevention of Healthcare-Associated Infections (HAIs).

September 16, 2015

Community Pharmacy Survey on Patient Safety Culture: 2019 User Comparative Database Report.

April 17, 2019

Surveys on Patient Safety Culture (SOPS) Ambulatory Surgery Center Survey: 2020 User Database Report.

March 18, 2020

AHRQ Nursing Home Survey on Patient Safety Culture: 2019 User Comparative Database Report.

February 20, 2019

Medical Office Survey on Patient Safety Culture: 2018 User Database Report.

May 2, 2018

ASPEN Parenteral Nutrition Safety Summit.

March 21, 2012

"Good catch, Kiddo"--enhancing patient safety in the pediatric emergency department through simulation.

December 9, 2020

Impact of the Care Quality Commission on Provider Performance: Room for Improvement?

November 21, 2018

Obstetric Quality and Safety.

October 28, 2009

Hospital Survey on Patient Safety Culture: 2018 User Database Report.

April 4, 2018

Improving inpatient mental health medication safety through the process of obtaining HIMSS Stage 7: a case report.

November 21, 2018

A new category of "never events"-ending harmful hospital policies.

November 9, 2022

Utilizing a Systems and Design Thinking Approach for Improving Well-Being Within Health Professional Education and Health Care.

January 16, 2019

Relationships between pediatric safety indicators across a national sample of pediatric hospitals: dispelling the myth of the "safest" hospital.

June 22, 2022

Patients' perceptions of importance for self-administered correct site surgery checklist: a multisite study.

June 8, 2022

Acute clinical deterioration and consumer escalation: the understanding and perceptions of hospital staff.

August 31, 2022

Making Healthcare Safer III.

March 18, 2020

Preventing Healthcare-Associated Infections: Results and Lessons Learned from AHRQ's HAI Program.

October 29, 2014

A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals.

October 22, 2008

Partnering with Patients and Families to Design a Patient- and Family-Centered Health Care System: Recommendations and Promising Practices.

June 4, 2008

More than half a million heart surgery patients at risk of a dangerous infection.

October 26, 2016

Washington Hospital Center safety program seeks to catch 'near-misses.'

August 17, 2011

Hospitals scramble on the front lines of drug shortages.

April 25, 2012

Meet the cancer patient in room 52: his name is Joseph, but call him Joe.

April 22, 2015

The Quality in Australian Health Care Study.

March 27, 2005

The Veterans Affairs root cause analysis system in action.

March 27, 2005

Related Resources

WebM&M Cases

A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion.

July 31, 2023

Healthcare workers' experiences of patient safety in the intensive care unit during the COVID-19 pandemic: a multicentre qualitative study.

July 12, 2023

Identification of patient safety threats in a post-intensive care clinic.

May 31, 2023

Effects of tall man lettering on the visual behaviour of critical care nurses while identifying syringe drug labels: a randomised in situ simulation.

April 20, 2022

Using smart IV infusion pumps outside of patient rooms.

February 2, 2022

Acting between guidelines and reality- an interview study exploring the strategies of first line managers in patient safety work.

February 3, 2021

Partnering with families and patient advocates: another line of defense in adverse event surveillance.

August 14, 2019

Hospitals look to computers to predict patient emergencies before they happen.

May 22, 2019

Evaluation of medication errors at the transition of care from an ICU to non-ICU location.

March 27, 2019

WebM&M Cases

One Bronchoscopy, Two Errors

January 1, 2019

Case not closed: prescription errors 12 years after computerized physician order entry implementation.

January 31, 2018

Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: a systematic review and meta-analysis.

April 26, 2017

February 8, 2017

Learning from excellence in healthcare: a new approach to incident reporting.

October 19, 2016

Incident and error reporting systems in intensive care: a systematic review of the literature.

February 3, 2016

Higher quality of care and patient safety associated with better NICU work environments.

September 2, 2015

An analysis of near misses identified by anesthesia providers in the intensive care unit.

July 15, 2015

Understanding the nature of medication errors in an ICU with a computerized physician order entry system.

February 11, 2015

Computerized physician order entry in the cardiac intensive care unit: effects on prescription errors and workflow conditions.

April 30, 2014

Transitioning Newborns From NICU to Home: A Resource Toolkit.

January 15, 2014

Characterising the complexity of medication safety using a human factors approach: an observational study in two intensive care units.

November 6, 2013

Impact of contact isolation for multidrug-resistant organisms on the occurrence of medical errors and adverse events.

October 23, 2013

Improving adverse drug event detection in critically ill patients through screening intensive care unit transfer summaries.

July 31, 2013

A clinical case of electronic health record drug alert fatigue: consequences for patient outcome.

June 12, 2013

Comparison of intensive care unit medication errors reported to the United States' MedMarx and the United Kingdom's National Reporting and Learning System: a cross-sectional study.

May 29, 2013

Targeted versus universal decolonization to prevent ICU infection.

May 1, 2013

Computerized prescriber order entry and opportunities for medication errors: comparison to tradition paper-based order entry.

March 20, 2013

The effects of computerized provider order entry implementation on communication in intensive care units.

February 20, 2013

Changes in end-user satisfaction with computerized provider order entry over time among nurses and providers in intensive care units.

November 28, 2012

AHRQ patient safety project reduces bloodstream infections by 40 percent.

September 19, 2012

See More About The Topic

Intensive Care Units

Health Care Providers

Health Care Executives and Administrators

Critical Care

Medication Errors/Preventable Adverse Drug Events

Computerized physician order entry, a factor in medication errors: descriptive analysis of events in the intensive care unit safety reporting system.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Computerized physician order entry, a factor in medication errors: descriptive analysis of events in the intensive care unit safety reporting system.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site