Question

What are the benefits and risks of integrating the CPOE and clinical decision support technologies with regard to improving patient safety

Answer 1

Ans) A CPOE system can prevent errors at the ordering and transcribing stages by (at a minimum) ensuring standardized, legible, and complete orders.

- CPOE systems are generally paired with some form of clinical decision support system (CDSS), which can help prevent errors at the medication ordering and dispensing stages and can improve safety of other types of orders as well. A typical CDSS suggests default values for drug doses, routes of administration, and frequency and may offer more sophisticated drug safety features, such as checking for drug allergies or drug–drug or even drug–laboratory (e.g., warning a clinician before ordering a nephrotoxic medication in a patient with elevated creatinine) interactions. The most sophisticated CDSSs prevent not only errors of commission (e.g., ordering a drug in excessive doses or a drug to which the patient has a known allergy), but also of omission (e.g., failing to order prophylaxis against deep venous thrombosis in a patient who underwent joint replacement surgery). CDSSs are also increasingly being deployed to address overuse—for example, a systematic review of CPOE for radiologic studies found that CDSS can improve adherence to guidelines for diagnostic imaging and reduce overall test usage.

Evidence of Effectiveness:
- CPOE offers numerous advantages over traditional paper-based order-writing systems. Examples of these advantages include: averting problems with handwriting, similar drug names, drug interactions, and specification errors; integration with electronic medical records, clinical decision support systems, and adverse drug event reporting systems; faster transmission to the laboratory, pharmacy, or radiology department; ability to recommend alternative tests or treatments that may be safer or lower cost; and potential economic savings. Supported by early evidence, the proposed benefits of CPOE served as a core part of the argument for federal funding to support the widespread implementation of CPOE.

- These proposed benefits have been borne out to some extent, principally with regard to improving medication safety. Specifically, CPOE appears to be effective at preventing medication prescribing errors. A 2013 meta-analysis found that the likelihood of a prescribing error was reduced by 48% when using CPOE compared with paper-based orders, which translates into more than 17 million medication errors prevented yearly in United States hospitals. Studies of e-prescribing systems—CPOE systems used primarily in outpatient practices that allow direct transmittal of prescriptions to pharmacies—have also found similar effectiveness at preventing outpatient prescribing errors.

- The effect of CPOE on clinical adverse drug event rates is less clear. Other reviews have found that CPOE does not reliably prevent patient harm, and high rates of adverse drug events persist in some hospitals with entirely computerized order entry systems. One interpretation of these results is that clinical decision support is the key intervention in reducing errors, and that, in the absence of CDSS, CPOE may prevent mostly clinically inconsequential errors. However, usability testing has demonstrated that CPOE systems with clinical decision support still allow unsafe orders to be entered and processed, and that clinicians can bypass safety steps with little difficulty. Another interpretation is that a significant proportion of medication errors occur at the dispensing and administration stages, and CPOE may not prevent these errors. Promising error reduction strategies in the setting of dispensing and administration include involving unit-based pharmacists and using barcode medication administration systems. Yet even as CPOE improves some aspects of patient safety, there is growing recognition that it can also lead to new safety concerns—particularly if the system is poorly designed.