|Year : 2013 | Volume
| Issue : 3 | Page : 180-183
Computerized provider order entry system: Solution to improve patient safety
Ashgar Ehteshami1, Sakineh Saghaeiannejad1, Nahid Tavakoli1, Fahimeh Sadeghi1, Vahideh Shirzad1, Mahtab Kasaei2
1 Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Health Information Technology, School of Health Management and Information Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
|Date of Web Publication||20-Mar-2014|
Department of Health Information Technology, Faculty of Health Management and Information Sciences, Isfahan University of Medical Sciences, Isfahan
Source of Support: None, Conflict of Interest: None
Introduction: Nowadays patient safety is one of the biggest concerns that health care organizations are faced with and medication errors is the most common cause of patient safety threatening. Low access to information during the decision-making and poor communication between care team members are the leading cause of medical errors that appear in most handheld systems. Therefore, this study investigated the knowledge of Physicians, nurses and pharmacy personnel about CPOE in Ayatollah Kashani Academic hospital in Isfahan, Iran to improve patient safety. Materials and Methods: This is a descriptive cross-sectional study in which 213 physicians', nurses' and pharmacy personnel's knowledge was surveyed by the questionnaire with 76 items. In Ayatollah Kashani hospital, we measured the knowledge of all 58 physicians and 10 pharmacy personnel about CPOE, but we sampled nurses by Morgan table and the 95% confidence level (144 nurses). Obtained data were analyzed with Statistical Package for the Social Sciences software (SPSS 16) and descriptive statistics were used to examine measures of compliance. Results: The findings indicated that knowledge of physicians, nurses and pharmacy personnel about CPOE was relatively desirable (65%). Their knowledge about the CPOE roles in medical prescription, dispensing, administration, time required in providing care, productivity, patient safety, and costs were 69%, 58%, 69%, 62%, 69%, 77% and 64%, respectively. Conclusion: Knowledge of physicians, nurses and pharmacy staff about CPOE was desirable; therefore, to improve the present situation, education, investment and infrastructure provision are necessary.
Keywords: Computerized provider order entry, knowledge, medical error, patient safety
|How to cite this article:|
Ehteshami A, Saghaeiannejad S, Tavakoli N, Sadeghi F, Shirzad V, Kasaei M. Computerized provider order entry system: Solution to improve patient safety. Int J Health Syst Disaster Manage 2013;1:180-3
|How to cite this URL:|
Ehteshami A, Saghaeiannejad S, Tavakoli N, Sadeghi F, Shirzad V, Kasaei M. Computerized provider order entry system: Solution to improve patient safety. Int J Health Syst Disaster Manage [serial online] 2013 [cited 2021 Jun 21];1:180-3. Available from: https://www.ijhsdm.org/text.asp?2013/1/3/180/129182
| Introduction|| |
Nowadays patient safety is one of the biggest concerns that health care organizations are facing with and medication errors are the most common causes of treats to patient safety. Low access to information during the decision-making and poor communication between care team members are the leading cause of medical errors that appear in most handheld systems. This error affects all aspects of medical treatment, including the transcription, dispensing and distribution of drugs. , Twenty percent of medical errors are from medication errors, of which 39% occur during prescription, 11% occur during transcribing orders into drug medication cards, 12% occur by pharmacists during dispensing, and 38% occur during medication administration by nurses.  According to Safari's results in Massachusett hospital, 56% of medication errors occur during prescription phase, 34% in medication administration phase, 6% in dispensing phase and 4% during distribution. 
According to the IOM,  , in the U.S hospitals, Almost 98,000 patients die due to medical errors, each year, and 65% of Americans are grappling with medication errors. Also, 13% of healthcare sources are spent on this problem.  The cost of medical errors in the U.S estimated to be 37.6 to 50 billion dollars annually, in which 17 to 29 billion dollars of this amount are related to preventable medical errors. In the UK National Health System, the cost of medication errors was 500 million $ as well as the increase in patients duration of stay. 
In Iran, according to the Ministry of Health and Medical Education, spend millions of dollars every year due to medical errors and care complications from a prolonged stay in hospital.  According to Valizadeh, the drug-related precautions are not met in 77.5% of cases, drug interactions have not been considered in 14.2% of cases, the interval between medication administration and its time was not compliance with physician orders in 14.8% of cases, and nurses forget to administer the ordered drugs.  Also, according to Mohamadnejad, the most common types of medication errors reported include the wrong amount of drug administered and the wrong infusion rate, and the most medication errors had occurred in intravenous injection (35/51%). 
It should be mentioned that almost all medical errors are preventable. Therefore, we can use information technology to accurately document data, faster and for better clinical and pharmaceutical information retrieval. There are many information systems for the collection and management of patient information and safety; however, more attention is focused on CPOE that has the potential to improve the errors caused by transcription, drugs prescription and distribution as CPOE reduces 83% of errors. ,, In addition, a consortium of several corporations working for the patient safety, has introduced CPOE as one of the three solutions that improve patient safety. 
Medical errors result from problems of information storage and retrieval. Therefore, the solution to reduce errors is improving mechanisms for the gathering, analyzing and using of information and knowledge. Thus, in this study, we assessed the knowledge of physicians, nurses and pharmacy personnel about CPOE system.
| Materials and Methods|| |
This research is an applied, descriptive cross-sectional study, in which 213 physicians', nurses' and pharmacy personnel's knowledge about the CPOE system surveyed by the questionnaire with 76 items. In Ayatollah Kashani hospital, Isfahan, Iran, we measured knowledge of all 58 physicians and 10 pharmacy personnel about CPOE, but we sampled nurses by Morgan table and the 95% confidence level (144 nurses). Content and constructive validity and reliability of the questionnaire was confirmed with a correlation coefficient of 0.86. Obtained data were analyzed with SPSS 16 software and descriptive statistics were used to examine measures of compliance.
| Result|| |
According to the finding in [Table 1], the general knowledge of physicians, nurses and pharmacy personnel about the CPOE system was relatively desirable (65%). The most and the least knowledge of the CPOE system was related to patient safety (77%) and dispensing errors controlling (58%), respectively.
ENT specialists with over 20 years of experience had the most knowledge of the role of CPOE systems in the control of prescribing errors and the orthopedists and nurses with less than 5 years of experience had the least knowledge in this area. Physical therapists with 10-15 years of experience had the most knowledge of the role of CPOE systems in the control of dispensing errors and the orthopedists and dispensers with 10-15 years of experience had the least knowledge in this area.
|Table 1: Score of physicians, nurses and pharmacy staff' knowledge about CPOE|
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Most knowledge of the system in dose errors controlling was related to ENT specialists, and personnel with MSc degree and over 20 years of experience. Despite, physical therapists and technicians with 15-20 years of experience had the least knowledge in this area.
The most knowledge of the CPOE system's role in the area of the time required for patient care was related to pharmacy technicians and psychologists. But, the least knowledge in this area was related to orthopedists and nurses with 15-20 years of experience. Subspecialists, ENT specialists and pharmacy personnel had the most knowledge of the CPOE role in productivity, but, orthopedists, nurses and pharmacy technicians with 15-20 years of experience had the least knowledge in this area.
In patient safety area, surgeons and pharmacy personnel with MSc degree and 5-10 years of experience had the most knowledge; but, orthopedists and pharmacy technicians with 15-20 years of experience had the least knowledge in this area.
The most knowledge of the CPOE system's role in medical care costs was related to psychologists, ENT subspecialists and pharmacy technicians; but, the least knowledge in this area was related to orthopedists and nurses with 5-10 years of experience.
In general, ENT specialists, pharmacy personnel, subspecialists, staff with 5-10 years of job experience had the most knowledge of CPOE, and, technicians, orthopedists, nurses and staff with 15-20 years of experience had the least knowledge in the all areas of the CPOE system.
| Discussion|| |
Physicians', nurses' and pharmacy staffs' knowledge of CPOE role in controlling prescription errors was relatively desirable that are consistent with the results of the Micro; According to Micro et al., computerized provider order entry impacts on prescribing error elimination and diagnoses documenting errors.  Teich et al., also, found that CPOE has the ability to prevent medication errors, improve quality of care, reduce costs by providing feedback to clinicians involved in drug affairs and is the powerful and effective tool for improving the physicians prescribing the manner of drugs.  To increase physicians', nurses' and pharmacy staffs' knowledge of CPOE role in the control of prescription errors, we recommend the following training priorities: Standardization of medication prescriptions; Prescription with flexible formats; Providing providers' orders in the medical care site (bedside); Impact of CPOE on medical risk during prescription; Impact of CPOE on illegibility errors; providing the latest information on updated prescription drugs; and the Impact of CPOE on unnecessary prescription of drugs due to the insistence of the patient.
Allenet et al., found that successful implementation of a CPOE system depends on users' perception of the system. They concluded that physicians have a positive attitude towards the CPOE system and the strong support of the clinical staff and wards heads have been very important in the successful implementation of CPOE. According to their findings, assigning a pharmacist to implement CPOE systems can lead to success; their participation in the implementation of CPOE is likely to lead to further improvement in user satisfaction and interaction with each other. In CPOE system development are required for pharmacists as the key members to play a role.  In our study, the knowledge of the physicians, nurses and pharmacy staff about the CPOE role in the controlling of dispensing errors was moderate (58%). Their knowledge was assessed at an acceptable level about of CPOE impact on the prevention of drug interactions and drug allergies before medication delivery; and patient's drug history supports during dispensing prescriptions. These results indicate that the two are aligned. We recommend the following trainings: Impact of CPOE on drug distribution time, volume of accepted prescriptions at the pharmacy, pharmacy staff workload, prescriptions documentation at the pharmacy, prevention of drug interactions with patient and food before delivery, ability to identify forged signatures of physicians during drugs dispensing, support for drug-dispensing process, and ability to distribute equivalent drugs.
Knowledge of the CPOE role in controlling the dose errors was relatively desirable that are consistent with the results of the Bates; According to his study, CPOE significantly reduced the dose error rates, errors that are very common and cause additional workload in hospitals, but, most of them have less potential to harm the patients; so that, a small amount of them causes damage; some leads to preventable adverse events.  To improve knowledge of the CPOE role in controlling dose errors, we recommend that appropriate training to be held including dose calculating abilities, and the CPOE impacts on errors due to medication administration for wrong patient.
Also, we recommend that training to be held on the CPOE that effects on physicians work hours, the time spent for nursing services, duration of stay, time to do administrative and therapeutic processes, and examination time. According to Van Doormaal, physicians and nurses are positive about the implementation and acceptance of CPOE, However, this system can be further improved in clinical practice areas. 
Knowledge of the CPOE role in productivity was relatively desirable that are consistent with the results of Chan and Sengstack. According to Chan, user-oriented CPOE can cause an increase in labor productivity, ease of use and increase the likelihood of successful implementation of CPOE.  Sengstack also found that medication errors have a large impact on mortality, sickness and hospital staff productivity. Although, CPOE is an expensive and complex system, but, it is one of the best solutions to significantly reduce medication errors in healthcare organizations.  In this area, the three item users need more training to include CPOE impact on the revenues of service providers, compliance with clinical guidelines, and performance monitoring tool for physicians.
The knowledge of the CPOE role in patient safety was relatively desirable. According to Riedmann et al., CPOE can reduce medication errors and adverse drug effects and subsequent increase patient safety in healthcare organizations; but, this system leads to the creation of additional workload and users ignoring and their fatigue due to the desire to build unnecessary warnings. They pursued efforts to achieve a comprehensive context model to prioritize drug safety alerts in CPOE and we can use their findings as the development of drug safety alerts in CPOE. 
In the area of the role of the CPOE system on costs and staffs' knowledge were relatively desirable that are consistent with the results of Sheikhtaheri and Bates. According to Sheikhtaheri, the system implementation and maintenance costs are high; however, the evidence suggests that the economic benefits derived from it is greater than its cost. Thus, we can conclude that in order to reduce errors and patient safety, use of this system is the worth investment.  Also, Bates et al., found that side effects of medications are both costly and cause serious injuries during hospitalization were.  In this area, some item users need more training to include CPOE impact on the hardware and software costs, space required for archiving the cost of drug therapy, providers' income, and dose calculating ability according to the patients' economic conditions.
According to the findings, in most cases, orthopedists have less knowledge of the CPOE system (among physicians). Staffs with 15-20 years of professional experience and technicians have little familiarity with CPOE systems that are consistent with the results of Wolf et al. They concluded that a high percentage of medication errors occur due to inexperience nurses. 
Overall, the mean knowledge of physicians, nurses and pharmacy staff about CPOE was relatively desirable that are consistent with the results of Khajouei et al. They concluded that after a decade, CPOE users were satisfied about ease of use of the system, its impact on efficiency, medication security, and workflow. 
According to Leung et al., using a CPOE reduced the 33.5% of the drug side/adverse effects. Although the incidence of drugs adverse effects has increased, but their results support using CPOE systems as a means of reducing drug side/adverse effects and injuries. Medication side/adverse effects may reduce by revising CPOE and concomitant utilization of CPOE along with decision support system. 
| Conclusion|| |
The mean knowledge of physicians, nurses and pharmacy staff of CPOE system was desirable and acceptable, in Ayatollah Kashani academic hospital. According to the findings, some challenges about CPOE utilization include: Little knowledge of physicians, nurses and pharmacy staff about CPOE; Staff inadequate trust to new technologies; Lack of CPOE hardware and software; and the high cost of CPOE equipment. Therefore, we recommend holding courses for physicians, nurses and pharmacy staff to improve their knowledge of the CPOE and its implementation. Also, hardware and software requirement provisions and installation are important.
| References|| |
|1.||Hajibabaee F, Joolaee S, Peyravi H, Haghani H. The relationship of medication errors among nurses with some organizational and demographic characteristics. Nerses Res 2011;6:83-92. |
|2.||Sadoughi F, Ghazisaeidi M, Mehrabi M, Kimiafar K, Ramezanghorbani N. Health Information Management Technology. Tehran: Jafari; 2011. |
|3.||Medication Errors. Ministry of Health, Drug and Food Department; 2011 [2013/06/20]; Available from: http://fdo.behdasht.gov.ir/index.aspx?siteid = 114 and pageid = 32110 and newsview = 25539. [Last accessed on 2013 Jun 20]. |
|4.||Safari R. Introduction to Cpoe. 2009 [2013/06/20]. Avail able from: http://www.pezeshk.us/?p = 17342 [Last accessed on 2013 Jun 20]. |
|5.||Wager K, Lee F, Glaser J. Health Care Information Systems-A Practical Approach for Health Care Management. 2 nd ed. Hoboken: Jossey-Bass; 2009. |
|6.||Valizade F, Ghasemi F, Haghi S, Delfan B, Mohsenzadeh A. Study of medication errors in a pediatric hospital records. Journal of Pediatrics Diseases 2004;18. |
|7.||Mohammadnejad E, Hojati H, Sharifnia H, Ehsani R. Study of medication errors and rates in nursing students in tehran education of hospital. J Med Ethics History Med 2010;3:60-9. |
|8.||Moghaddasi H, Sheikhtaheri A, Hashemi N. Reducing medication errors: Role of computerized physician order entry system. Health Manag 2007;10:57-69. |
|9.||Sengstack P, Gugerty B. CPOE systems: Success factors and implementation issues. J Healthc Inf Manag 2004;18:36-45. |
|10.||Mirco A, Campos L, Falcão F, Nunes JS, Aleixo A. Medication errors in an internal medicine department. Evaluation of a computerized prescription system. Pharm World Sci 2005;27:351-2. |
|11.||Teich JM, Marchia PR, Schmiz JL, Kuperman GJ, Spur CD, Bates DW. Effects of computerized physician order entry on prescribing practices. Arch Intern Med 2000;160:2741-7. |
|12.||Allenet B, Bedouch P, Bourget S, Baudrant M, Foroni L, Calop J, et al. Physicians′ perception of CPOE implementation. Int J Clin Pharm 2011;33:656-64. |
|13.||Bates DW, Teich JM, Lee J, Seger D, Kuperman GJ, Ma′Luf N, et al. The Impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc 1999;6:313-21. |
|14.||Bates DW, Leape LL, Cullen DJ, Laird N, Petersen LA, Teich JM, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA 1998;280:1311-6. |
|15.||Chan J, Shojania KG, Easty AC, Etchells EE. Does user-centred design affect the efficiency, usability and safety of CPOE order sets? J Am Med Inform Assoc 2011;18:276-81. |
|16.||Riedmann D, Jung M, Hackl WO, Stühlinger W, van der Sijs H, Ammenwerth E. Development of a context model to prioritize drug safety alerts in CPOE Systems. BMC Med Inform Decis Mak 2011;11:35. |
|17.||Sheikhtaheri A, Hashemi N. Patient safety and the need for information technology. Homaye Salamat 2007;4. |
|18.||Wolf ZR, Hicks R, Serembus JF. Characteristics of medication errors made by students during the administration phase: A descriptive study. J Prof Nurs 2006;22:39-51. |
|19.||Khajouei R, Wierenga PC, Hasman A, Jaspers MW. Clinicians satisfaction with CPOE ease of use and effect on clinicians′ workflow, efficiency and medication safety. Int J Med Inform 2011;80:297-309. |
|20.||Leung AA, Carol Keohane BS, Simon SR, Coffey M, Kaufman N, Cadet B, et al. Impact of vendor computerized physician order entry in community hospitals. J Gen Intern Med 2012;27:801-7. |