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Digital Drug Ordering Reduces Errors but Exposes Weaknesses in System

CPOE shows importance of accurate data entryGarbage in, garbage out. The old adage holds true in many aspects of our lives. And, as the healthcare system is learning, life in our data-driven society is placing crucial importance on the accuracy of the information being put into the nation’s electronic medical records systems.

According to a story published this month in USA Today, hospital errors are the third leading cause of death in the United States. And, one system that was developed to help bring those numbers down may have actually opened up a stinging vulnerability.

CPOE, or computerized physician order entry, is the name of the system developed to fulfill prescription orders as part of the electronic medical record requirements of the Affordable Care Act. The system digitizes the process of a prescription order, from the physician’s instruction to the actual distribution of the drug. It cross-checks for errors and adds a second level of safety and clarity over what was previously available with just a simple paper-and-pen ordering system.

To do this, however, CPOE depends on complete accuracy in the medical records and notes that have been input into the EMR system. This has created an interesting dilemma.

In a system that medical professionals complain is too complicated, bloated, and poorly designed to allow for quick and efficient use, serious medication errors have been successfully reduced by 88%. But, potentially fatal mistakes are still making it through the system and more than one in ten of them are because of errors in the electronic medical records themselves. A recent analysis performed by Leapfrog Group, an organization focused on rating the nation’s hospitals, suggests that these errors, oversights, and omissions account for some 40% of the most serious errors allowed by CPOE.

As is the case with the rollout of any new technology, the electronic medical records mandate demonstrated the necessity of focusing attention on educating users on the proper use of the new tool. Technology is all too often seen as a complete solution rather than the means to accomplishing a solution. And when a patient’s life can end because of a typographical error, the importance of such care and accuracy can’t be overstated.