A Web-based simulation tool to test the ability of computerized physician order entry systems has found the systems on average miss half of routine medication orders and a third of potentially fatal errors, according to the Leapfrog Group, a coalition of employer purchasers working to improve patient safety.

Washington-based Leapfrog built the CPOE Evaluation Tool in partnership with the Institute for Safe Medication Practices and four CPOE experts: David Bates, M.D., of Partners HealthCare System; David Classen, M.D. of Computer Sciences Corp.; Marc Overhage, M.D., of Regenstrief Institute; and Thomas Payne, M.D., of the University of Washington. Grants from the California Healthcare Foundation and Agency for Healthcare Research and Quality funded the initiative.

From June 2008 through January 2010, 214 hospitals used the tool to evaluate their CPOE systems. Adult and pediatric hospitals were given different scenarios, with 10 test patients and 50 medication orders. Each of the orders would result in an adverse drug event, some of them potentially fatal.

The results: In 52 percent of 8,716 tests of flawed orders at adult hospitals, clinicians did not receive an appropriate warning. CPOE systems at pediatric hospitals failed to give an appropriate warning for 42 percent of 1,731 flawed orders.

Adult hospital systems missed 33 percent of intentionally flawed medication test orders that could result in death; pediatric systems missed 34 percent.

The Leapfrog Group is calling on hospitals that have CPOE to use the simulation tool as an integral part of their quality assurance and improvement processes. The organization says 96 percent of hospitals that have gone through the simulation twice have improved in one or more test categories.

More information on the CPOE Evaluation Tool is available at leapfroggroup.org.

--Joseph Goedert


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