While computerized physician order entry is expected to significantly reduce adverse drug events, systems must be implemented thoughtfully to avoid facilitating certain types of errors. A forcing function that mandated correct patient identification resulted in a moderate decrease in wrong-patient prescribing errors within a computerized provider order entry system.

This article details how one academic medical center engaged housestaff in tactics to achieve higher compliance with medication reconciliation.

Unintended consequences of adopting computerized provider order entry (CPOE) systems, including increased mortality, have been reported. This study examined the number of preventable adverse events before and after implementation of a CPOE system with clinical decision support (CDSS). Investigators discovered significant reductions in overall errors, dispensing errors, and drug-choice errors. While past commentaries have recommended caution in overstating the benefits of CPOE and CDSS, they do reinforce the need to adequately evaluate new information systems when incorporated. This study represents a good example of such evaluation, as the authors point out necessary system modifications that will help prevent additional adverse events in their hospital setting.

This article summarizes the structure, funding, organization, and methods of an independent and clinically based surveillance program identifying serious and unrecognized adverse drug events (ADEs). The authors provide a detailed account of the process involved, from investigating a possible serious ADE to disseminating their findings to the Food and Drug Administration (FDA), manufacturers, conferences, journals, and the news media. They also share initial results of their operations with details of 16 drugs associated with serious ADEs, including tabular display of the cases reported and the inconsistencies in the dissemination of safety information. The authors conclude by sharing potential implications of the program’s efforts and how this surveillance method may provide additional opportunity to detect and prevent serious ADEs.