Study Finds Automated Healthcare System Promotes Errors
Posted: 06.01.05 - By Teresa von Fuchs

According to a recent study by the University of Pennsylvania School of Medicine’s Ross Koppel, Ph.D., automated prescription systems can increase the risk of medication errors. Koppel’s findings were the result of a two-year study at a 705-bed urban teaching hospital. Researchers surveyed staff members, including nurses, physicians, pharmacists and IT staff on their use of the computerized physician order entry (CPOE) system. Problems with the system included CPOE displays that blocked a coherent view of patients’ medications, pharmacy inventory displays that were mistaken for dosage guidelines and rigid ordering formats that caused incorrect orders.

The healthcare industry has championed specially designed software systems such as CPOEs as the cornerstone of improved patient safety. Koppel, however, believes this to be a false hope. “Good CPOE systems are, indeed, very helpful and hold great promise,” he told the UPenn Press, “but, as currently configured, there are at least two dozen ways in which CPOE systems significantly, frequently and commonly facilitate errors.”

Koppel grouped the 22 common errors into two main categories: information errors and human-machine interface flaws. Information errors result from fragmentation of data and information, or when there is a failure to fully integrate a hospital’s multiple computer and information systems. An example of these errors is when a physician orders an incorrect drug dosage due to a misunderstanding of the CPOE display.

Human-machine interface flaws reflect machine rules that do not correspond to work flow or usual behaviors. For example, within the CPOE system studied, up to 20 screens might be needed to view all of one patient’s medications—a lot to scroll through if you’re looking for possible interactions.
The study cites that many CPOE systems don’t take into account how physicians actually work in a hospital and are created for an idealized setting where doctors work in a quiet environment and have time to carefully select orders.
The study suggests that application designers begin to “understand that their programs need to seamlessly integrate into an institutional context, one that operates 24/7, under great stress and with a constantly changing set of people, policies and practices.”


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