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Colombini N, Abbes M, Cherpin A, et al. Int J Med Inform. 2022;160:104703.
Computerized provider order entry (CPOE) refers to a system in which clinicians directly place orders electronically to be sent to the receiver (e.g., pharmacist). This French hospital analyzed hospital discharge orders (HDO) over a six-month period to evaluate the use rate of CPOE, prescription concordance between CPOE-edited HDO, exit prescriptions transcribed in the discharge summary, and prescribing error rate. Use of CPOE and pharmacist intervention reduced prescribing errors of hospital discharge orders.
Heed J, Klein S, Slee A, et al. Br J Clin Pharmacol. 2022;Epub Feb 16.
Hospitals in the US can evaluate the safety of their computerized provider order entry using a simulation tool such as the one provided by the Leapfrog Group. This study developed a similar simulation tool for use in the UK. Study participants rated 178 clinical scenarios for likelihood of occurrence, level of associated harm, and likelihood of harm. One hundred and thirty-one extreme or high-risk prescribing scenarios were developed and will be used to create the evaluation tool.
Kukielka E, Jones R. Patient Safety. 2022;4:49-59.
Medication errors can occur in all clinical settings, but can have especially devastating results in emergency departments (EDs). Between January 1, 2011, and December 31, 2020, 250 serious medication errors occurring in the ED were reported to the Pennsylvania Patient Safety Reporting System. Errors were more likely to occur on weekends and between 12:00 pm and midnight; patients were more likely to be women. Potential strategies to reduce serious medication errors (e.g., inclusion of emergency medicine pharmacists in patient care) are discussed.
LaScala EC, Monroe AK, Hall GA, et al. Pediatr Emerg Care. 2022;38:e387-e392.
Several factors contribute to pediatric antibiotic medication errors in the emergency department, such as the frequent use of verbal orders and the need for  weight-based dosing. Results of this study align with previous research and reinforce the need for further investigation and interventions to reduce antibiotic medication errors such as computerized provider order entry.
Grauer A, Kneifati-Hayek J, Reuland B, et al. J Am Med Inform Assoc. 2022;29:909-917.
Problem lists, while an important part of high-quality care, are frequently incomplete or lack accuracy. This study examined the effectiveness of leveraging indication alerts in electronic health records (EHR) (medication ordered lacking a corresponding problem on the problem list) in two different hospitals using different EHRs. Both sites resulted in a proportion of new problems being added to the problem list for the medications triggered. Between 9.6% and 11.1% were abandoned (order started but not signed), which needs further study.
Pueyo-López C, Sánchez-Cuervo M, Vélez-Díaz-Pallarés M, et al. J Oncol Pharm Pract. 2021;27:1588-1595.
Researchers in this study used healthcare failure mode and effect analysis (HFMEA) to identify and reduce errors during chemotherapy preparation. Nine potential failure modes were identified – wrong label, drug, dose, solvent, or volume; non-sterile preparation; incomplete control; improper packaging or labeling, and; break or spill – and the potential causes and effects. Potential approaches to reduce these failure modes include updating the Standard Operating Procedures (SOPs), implementing a bar code system, and using a weight-based control system.
Holmgren AJ, Bates DW. JAMA Netw Open. 2021;4:e2125173.
Hospitals participating in the voluntary Leapfrog program must publicly report data on several quality measures. Hospitals that participated in the Computerized Provider Order Entry (CPOE) Evaluation Tool, which measures medication safety, had a mean score of 59.3% at baseline. Hospitals that received negative feedback showed greater improvement than hospitals that received positive feedback, demonstrating the utility of public reporting in improving quality.
Chua K-P, Brummett CM, Conti RM, et al. Pediatrics. 2021;148:e2021051539.
Despite public policies and guidelines to reduce opioid prescribing, providers continue to overprescribe these medications to children, adolescents, and young adults. In this analysis of US retail pharmacy data, 3.5% of US children and young adults were dispensed at least one opioid prescription; nearly half of those included at least one factor indicating they were high risk. Consistent with prior research, dentists and surgeons were the most frequent prescribers, writing 61% of all opiate prescriptions.
Alshehri GH, Keers RN, Carson-Stevens A, et al. J Patient Saf. 2021;17:341-351.
Medication errors are common in mental health hospitals. This study found medication administration and prescribing were the most common stages of medication error. Staff-, organizational-, patient-, and equipment-related factors were identified as contributing to medication safety incidents.
Udeh C, Canfield C, Briskin I, et al. J Am Med Inform Assoc. 2021;28:1791-1795.
Computerized provider order entry (CPOE) systems have the potential to reduce error, but their poor CPOE design, implementation and use can contribute to patient safety risks. In this study, researchers found that restricting the number of concurrently open electronic health records did not significantly reduce wrong patient selection errors in their hospital’s CPOE system.
Koeck JA, Young NJ, Kontny U, et al. Pediatric Drugs. 2021;23:223-240.
Pediatric patients are at risk for medication prescribing errors due to weight-based dosing. This review analyzed 70 interventions aimed at reducing weight-based prescribing errors. Findings indicate that bundled interventions are most effective, and that interventions should include substitute or engineering controls (e.g., computerized provider order entry) along with administrative controls (e.g., expert consultation).

A 4-year-old (former 33-week premature) boy with a complex medical history including gastroschisis and subsequent volvulus in infancy resulting in short bowel syndrome, central venous catheter placement, and home parenteral nutrition (PN) dependence was admitted with hyponatremia. A pharmacist from the home infusion pharmacy notified the physician that an error in home PN mixing had been identified; a new file had been created for this chronic PN patient by the home infusion pharmacy and the PN formula in this file was transcribed erroneously without sodium acetate.

Cerqueira O, Gill M, Swar B, et al. BMJ Qual Saf. 2021;30:1038-1046.
Computerized prescriber order entry (CPOE) systems embedded in electronic health systems alert clinicians to potential safety concerns such as drug-drug interactions or medication dosage errors. Results of this review indicate that alerts influenced prescriber behavior in most of the included studies. However, it is unclear whether these behavioral changes improve patient safety outcomes. Recommendations for future research include randomized controlled trials to determine which alerts maximize patient safety, while minimizing prescribers’ alert fatigue.
Srinivasamurthy SK, Ashokkumar R, Kodidela S, et al. Eur J Clin Pharmacol. 2021;77:1123-1131.
Computerized prescriber (or physician) order entry (CPOE) systems are widely used in healthcare and studies have shown a reduction in medication errors with CPOE. This study focused on whether CPOE systems improved the incidence of chemotherapy-related medication errors. The study included 11 studies in the review but only 8 studies were in the meta-analysis. The authors found that the use of CPOE was associated with an 81% reduction in chemotherapy-related medication errors, indicating that CPOE is a valuable strategy for this patient population.
Co Z, Holmgren AJ, Classen DC, et al. Appl Clin Inform. 2021;12:153-163.
Medication errors occur frequently in ambulatory care settings. This article describes the development and testing of an ambulatory medication safety evaluation tool, which is based on an inpatient version administered by The Leapfrog Group. Pilot testing at seven clinics around the US indicates that clinics struggled in areas of advanced decision support such as drug age and drug monitoring, and that most clinics lacked EHR-based medication reconciliation functions.
Kinlay M, Zheng WY, Burke R, et al. Res Social and Adm Pharm. 2021;17:1546-1552.
Computerized provider order entry (CPOE) systems have been advocated as a strategy to reduce medical errors, but some errors persist. This narrative review identified knowledge gaps in the relationship between CPOE systems and how systems-related errors change over time. Studies suggest that system-related errors persist with long-term use of CPOE systems, but future research should explore the types of errors that occur, when they occur, and the system factors contributing to the errors.

Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2021.

Alert fatigue is a recognized contributor to task burden and medical error. This report distilled monitoring, analysis, and optimization experiences to recommend strategies for improving the effectiveness of clinical audible alerts which includes the development of an overarching clinical decision support governance plan.
Dellinger JK, Pitzer S, Schaffler-Schaden D, et al. BMC Geriatr. 2020;20:506.
Polypharmacy in older adults is common and may increase risk of medication-related adverse events. This study found that an intervention combining educational training, tailored health information technology, and a therapy check process improved medication appropriateness in nursing home residents.