Kaushal R et al. 2003 "Effects of computerized physician order entry and clinical decision support systems on medication safety - a systematic review."

Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. Arch Intern Med 2003;163(12):1409-1416.
"Background: latrogenic injuries related to medications are common, costly, and clinically significant. Computerized physician order entry (CPOE) and clinical decision support systems (CDSSs) may reduce medication error rates. Methods: We identified trials that evaluated the effects of CPOE and CDSSs on medication safety by electronically searching MEDLINE and the Cochrane Library and by manually searching the bibliographies of retrieved articles. Studies were included for systematic re-view if the design was a randomized controlled trial, a nonrandomized controlled trial, or an observational study with controls and if the measured outcomes were clinical (e.g. adverse drug events) or surrogate (e.g. medication errors) markers. Two reviewers extracted all the data. Discussion resolved any disagreements. Results: Five trials assessing CPOE and 7 assessing isolated CDSSs met the criteria. Of the CPOE studies, 2 demonstrated a marked decrease in the serious medication error rate, 1 an improvement in corollary orders, 1 an improvement in 5 prescribing behaviors, and 1 an improvement in nephrotoxic drug dose and frequency. Of the 7 studies evaluating isolated CDSSs, 3 demonstrated statistically significant improvements in antibiotic-associated medication errors or adverse drug events and 1 an improvement in theophylline-associated medication errors. The remaining 3 studies had nonsignificant results. Conclusions: Use of CPOE and isolated CDSSs can substantially reduce medication error rates, but most studies have not been powered to detect differences in adverse drug events and have evaluated a small number of "homegrown" systems. Research is needed to evaluate commercial systems, to compare the various applications, to identify key components of applications, and to identify factors related to successful implementation of these systems."
"To systematically review the cummulative evidence on the effects of CPOE and CDSSs on medication safety."
Type Clinic
Primary care and specialty care
not applicable
Type of Health IT
Decision support system
Computerized provider order entry (CPOE)
Type of Health IT Functions
The authors define CPOE and CDSSs as follows: "Computerized physician order entry refers to a variety of computer-based systems that share the common features of automating the medication ordering process and that ensure standardized, legible, and complete orders. Clinical decision support systems are built into almost all CPOE systems to varying degrees. Basic clinical decision support provides computerized advice regarding drug doses, routes, and frequencies, and more sophisticated CDSSs can perform drug allergy checks, drug-laboratory value checks, and drug-drug interaction checks and can provide reminders about corollary orders (e.g. prompting the user to order glucose checks after ordering insulin) or drug guidelines. Clinical decision support systems may also be implemented without CPOE. Basic CDSSs often assist in tasks such as drug selection, dosing, and duration, and more refined CDSSs can incorporate patient- or pathogen-specific information. The ordering physician may view such advice and then proceed with a conventional handwritten medication order."
Workflow-Related Findings
"As users become accustomed to CPOE and CDSSs, they are likely to accept computer suggestions with minimal reflection, emphasizing the importance of testing decision support default settings and suggestions."
"When CPOE systems are not electronically linked to computerized pharmacy systems, pharmacists must manually reenter orders into the pharmacy system, with a resultant increase in chance of error."
"The trigger level for computerized warnings must be set to the appropriate sensitivity. In situations with a potential for significant harm, it is important that providers receive warnings without being overwhelmed by alarms of marginal value."
"Finally, physicians can electronically write an order in the wrong patient's record, analogous to handwriting an order in the wrong patient's medical chart."
Study Design
Systematic literature review
Study Participants
Twelve articles were included in the analysis: five evaluated CPOE with CDSSs and seven studies evaluated isolated CDSSs. "Studies were included for review if the design was RCT, a non-RCT controlled trial, or an observational study with controls and if the outcomes were clinical or surrogate markers." "Specifically, we sought articles describing computerized systems for performing general order entry or CDSSs for guiding physicians in the order-writing process. Computerized programs that screen for potential ADEs were not included, unless they interact with users during the order-writing process, and neither were CDSSs built into programmable intravenous infusion pumps. Although both of these practices play a role in improving medication safety, they do not affect the stage of order writing, which is the focus of this review."