CPOE-Unintended Results

As computerized physician order entry (CPOE) was introduced, the hope was that medication errors would decrease. The good news is that transcription errors from illegible handwriting has improved. The bad news is that unintended consequences of CPOE can increase error. One problem is an "illusion of communication" between caregivers when it is thought that the entry of data into the system is always seen by everyone else in the system. Juxtaposition errors can occur when practitioners must pick from long drop-down boxes. Overreliance on technology can also be dangerous when clinicians assume the computer won't allow significant dosing errors; in a soon-to-be-published study presented recently at the National Patient Safety Foundation Congress, researchers found 80% of significant dosing errors went through CPOE, unless stopped by a human.

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