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PSNet: Patient Safety Network
Journal Article

Error reduction in pediatric chemotherapy: computerized order entry and failure modes and effects analysis.

Kim GR, Chen AR, Arceci RJ, et al. Archives of pediatrics & adolescent medicine. 2006;160:495-8.

This study utilized a multidisciplinary team of oncology providers to conduct a failure mode and effects analysis (FMEA) and generate recommendations for implementing a computerized provider order entry (CPOE) system. Investigators tracked more than 1000 chemotherapy orders before and after CPOE implementation and discovered lower rates of ordering errors with the new process. Discussion includes specific recommendations that resulted from the FMEA and presentation of the error types (eg, order and treatment plan match, correct calculation, nursing checklist present) noted during the study period. The authors acknowledge the importance of CPOE as a tool to reduce chemotherapy-related medication errors and advocate for close collaboration among clinical and information technology experts to drive such interventions.