Technology can cause medication errors, study finds

One problem with computerized physician order entry systems, researchers say, is that systems aren't created with physician workflow in mind.

By Tyler Chin, AMNews staff. March 28, 2005.

As the cry grows louder to use information technology to cure the ills of the health care industry, a new study finds computers might not be the right prescription for communication problems.

In a study published in the March 9 Journal of the American Medical Association, researchers concluded that computerized physician order entry systems -- widely touted as tools to reduce medication errors and improve patient safety -- facilitated 22 types of medication errors at the Hospital University of Pennsylvania, a teaching hospital that is part of the University of Pennsylvania Health System and one of the earliest health systems in the country to use the technology.

A two-year examination of the TDS 7000 order entry system from Eclipsys Corp., Boca Raton, Fla., that the hospital used between 1997 and 2004, found that 45% (10 out of 22) of those errors were caused by the technology itself and the lack of connectivity between it and other departmental information systems at the hospital.

The remainder were caused by what the researchers described as "human-machine interface flaws," or the failure of the technology to reflect how doctors and organizations work.

"I'm not opposed to CPOE," said Ross Koppel, PhD, a sociologist at the Center for Clinical Epidemiology and Biostatistics at the University of Pennsylvania School of Medicine, and the principal author of the study, which was augmented by a JAMA editorial supporting its conclusions. "I think CPOE offers many advantages over a paper-based system, but using CPOE stupidly just enhances the errors that are already inherent in any system."