Leapfrog Group: CPOE could harm patients without proper monitoring

Without proper monitoring, health IT such as computerized physician order entry (CPOE) systems could inadvertently harm patients, according to a new report by the Leapfrog Group.

Using a web-based simulation tool, 214 hospitals tested their CPOE systems from June 2008 to January of this year for their ability to catch common medication errors, including errors that could lead to fatalities. The CPOE systems on average missed one-half of the routine medication orders (52 percent) and a third of the potentially fatal orders (32.8 percent), the Washington, D.C.-based health advocacy organization found.

“Nearly all of the hospitals improved their performance after adjusting their systems and protocols and running the simulation a second time,” stated the report.

The CPOE simulation is part of the annual Leapfrog Hospital Survey where 26 percent of the 1,244 hospitals that completed the survey in 2009 reported having a CPOE system in at least one inpatient department. With about two-thirds of hospitals either losing money or existing on minimal margins, many respondents said they need help to bring the technology to their communities.

The report recommended that there must be a testing and monitoring component for all technology adoption in hospitals alongside federal investment in technology.

“The evidence that CPOE saves lives and prevents the most common adverse event in hospitals--medication errors--remains abundant and urgent,” concluded the report. “CPOE systems can reduce adverse drug events by up to 88 percent, preventing 3 million medication errors in the U.S. each year…We will need to rely on advancing technology to support clinicians, and we will need to improve on the performance of that technology over time.”

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