An Etiology for Medication Ordering Errors in Computerized Provider Order Entry Systems (Illinois)

Project Details - Ongoing

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Standardization of orders using CPOE systems has been shown to improve healthcare quality and safety, resulting in reduced overall costs. Although existing research has identified several risks with CPOE-based ordering including medication errors and adverse drug events, much of this research is based on case studies, retrospective chart reviews, or other observational methods. Although these methods are useful, a more comprehensive method for studying CPOE-based medication ordering errors is needed.

This project will evaluate a CPOE-based function—medication voiding—that can be used to prospectively identify and document intercepted medication ordering errors. The medication voiding feature of the CPOE systems allows clinicians to identify and document that an existing order was placed in error, and remove it from a patient’s active medication list. In addition to the documentation of erroneous orders, the voiding process occurs within the medication ordering workflow of the clinician, making it a potentially useful mechanism for error identification, recording, and tracking.

The specific aims of the project are as follows:

  • Investigate clinician provided reasons for CPOE-based medication voiding. 
  • Identify intercepted medication ordering errors from voided orders, and their clinical impact. 
  • Develop statistical and descriptive models for characterizing intercepted medication ordering errors. 

Using a prospective study, the investigators will track and evaluate voided inpatient medication orders over a 12-month study period. Guided by principles and methods from human factors and medical error research, they will identify the characteristics of medication voiding, and the clinician-perceived reasons for medication voiding. Study findings can help to determine the appropriateness of using medication voiding as a mechanism for tracking, documenting, and studying medication ordering errors and their interception, as well as identify clinician-provided reasons for medication ordering errors. In addition, the study may provide user-centered insights to improve the usability of the voiding function and its integration into clinician medication ordering workflow.

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