Despite widespread adoption of computerized provider order entry, tests of those systems found a significant potential for adverse drug events.
In recent tests of hospital CPOE systems, 39 percent of potentially harmful drug orders were not flagged to alert clinicians to potential errors, and 13 percent of potentially fatal errors failed to trigger an alert, according to the Leapfrog Group.
Results of the study, based on data from 1,750 hospitals in 2015, showed little improvement for comparable data in 2014, which measures the ability of hospitals’ information systems to flag potential errors. The Leapfrog Group said the ability to catch errors improved by only 1 percent between 2014 and 2015.
Leapfrog, a coalition of large employers working to improve care quality, pulled CPOE data from its 2015 annual survey of hospitals covering a range of issues. Castlight Health, which offers a software platform to help employees make better healthcare decisions, provided analysis support.
“CPOE systems have done a remarkable job in reducing the likelihood of medication errors, but mistakes are still seen with far too much frequency,” says Leah Binder, president and CEO at 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.”
The study found that 96 percent of responding hospitals have a CPOE system in place, spurred by the federal Meaningful Use program, which provides financial incentives for adoption of electronic health records; one of the key objectives of the program is implementation and demonstrated use of CPOE systems. By contrast, only 33 percent of hospitals in 2010 had implemented CPOE systems.
Beyond just putting CPOE systems in place, Leapfrog asks hospitals to test their CPOE systems annually using a standard evaluation tool. To fully meet Leapfrog’s standard, hospitals must demonstrate that the system alerts physicians to at least 50 percent of common serious prescribing errors; and hospitals must show that physicians order at least 75 percent of inpatient medication orders through a CPOE system. Leapfrog says two-thirds of surveyed hospitals meet those standards for CPOE implementation and quality.
There is wide variation across the country in hospitals meeting the Leapfrog standards. States with the lowest percentage of hospitals meeting these criteria include Indiana (25 percent) and Nevada (35 percent); states with the best percentage of hospitals meeting the standards include Maine (85 percent), Georgia (83 percent) and New York (81 percent).
However, tests of CPOE systems found shortcomings in abilities to detect certain types of events that may lead to adverse drug events. Leapfrog said the most common unflagged errors related to medication or dosage include:
Inappropriate diagnosis, such as prescribing a beta blocker to a patient with asthma, which could cause complications.
Not incorporating kidney function into making a decision on a drug order, such as prescribing a drug that must be processed by the kidneys for a patient who has impaired kidney function, without reducing the dose accordingly.
Not indicating ongoing monitoring of a patient taking a prescription, such as failing to display a reminder to test drug levels after issuing a medication when such follow-up is clinically indicated.
Beyond just testing CPOE capabilities, the Leapfrog assessment also measured hospitals’ progress toward process improvement in catching drug errors. Hospitals can supplement computerized checks with manual reviews to promote medication safety. Medication reconciliation is the process of identifying the most accurate list of all medications a patient is taking—including name, dosage, frequency, and route—and using this list to provide correct medications for patients. This process can reduce medication errors and adverse drug events.
The analysis found that 62 percent of responding hospitals conduct all recommended medication reconciliation activities, and nearly all hospitals document patient medications at admission and share an updated medication list with patients and caregivers at discharge.
However, Leapfrog contends that hospitals could do more; it said that only 84 percent hold senior administrative leaders accountable for adherence to these processes, and 88 percent allocate staff and budget for developing best practices in this area.
"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.
Leapfrog’s data file on the surveyed hospitals is available here.
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