A shocking 39 percent of potentially harmful drug orders weren’t flagged by a computerized physician order entry (CPOE) system designed to do just that, according to the latest report from The Leapfrog Group.

Not all hospitals have implemented the systems but even those that have must double- and triple-check order to prevent harm, according to the report.

The report, Preventing Medication Errors in Hospitals, analyzes data collected in the 2015 Leapfrog Hospital Survey. The analysis by Castlight Health found that 13 percent of potentially fatal orders failed to trigger an alert by the system. 

“CPOE systems have done a remarkable job in reducing the likelihood of medication errors, but mistakes are still seen with far too much frequency,” said Leah Binder, president and CEO of Leapfrog. “Hospitals spend millions of dollars to implement CPOE systems, but our results clearly show that many hospitals’ systems are not operating as well as they should, putting patients’ lives at risk.”

Almost every (96 percent) reporting hospital now has a CPOE system, an increase from 33 percent in 2010 and just two percent when Leapfrog first began reporting on CPOE in 2001. CPOE is the best-known tool to prevent medication errors, which remain the most common mistake made in hospitals.

Nearly two-thirds of hospitals (64 percent) fully met Leapfrog’s CPOE standard for CPOE implementation and quality. Leapfrog’s standard requires a hospital to demonstrate that its system alerts physicians to at least 50 percent of common, serious prescribing errors. Hospitals must also place at least 75 percent of medication orders through a CPOE system.

CPOE use varies state by state. Among the states with the lowest percentage of hospitals meeting Leapfrog’s standard were Indiana (25 percent) and Nevada (35 percent). Five additional states had fewer than 50 percent of hospitals meeting the standard. The states with the most hospitals meeting the standard were Maine (85 percent), Georgia (83 percent) and New York (81 percent). Eight additional states reported 75 percent or more hospitals meeting the standard.

"It is critical that hospitals maintain well-functioning CPOE systems and proper accompanying manual reviews to ensure patients receive the best possible care,” said Kristin Torres Mowat, senior vice president of plan development and data operations at Castlight Health. “The absence of these systems increases the risk of a patient having an adverse drug reaction (ADR), which can result in a longer hospitals stay and average increased costs of $3,000 per patient. We have worked with Leapfrog to highlight the need for more checks and to educate consumers on the key quality and safety information they need to consider to make the best healthcare decisions.”