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Editorial Team. Technical Expert Panel. Copy URL. Background The digital transformation of medicine is perhaps best exemplified by computerized provider order entry CPOE , which refers to any system in which clinicians directly place orders electronically, with the orders transmitted directly to the recipient. The process of prescribing and administering a medication involves several steps, each of which has vulnerabilities that are addressed—to greater or lesser degrees—by CPOE: Ordering: the clinician must select the appropriate medication and the dose and frequency at which it is to be administered.
Transcribing: if handwritten, the prescription must be read and understood by the recipient usually a pharmacy technician or pharmacist.
Dispensing: the pharmacist must check for drug—drug interactions and allergies, then release the appropriate quantity of the medication in the correct form. Administration: the medication must be received by the correct person and supplied to the correct patient at the right time in the right dosage.
In hospitalized patients, nurses are generally responsible for this step, but in the outpatient setting, this step is the patient's or caregiver's responsibility. Evidence of Effectiveness CPOE offers numerous advantages over traditional paper-based order-writing systems. Types of Unintended Consequences of Computerized Provider Order Entry Systems More or new work for clinicians Unfavorable workflow issues Never-ending system demands Problems related to persistence of paper orders Unfavorable changes in communication patterns and practices Negative feelings toward the new technology Generation of new types of errors Unexpected changes in an institution's power structure, organizational culture, or professional roles Overdependence on the technology Reprinted with permission from Elsevier.
Department of Health and Human Services. Readers should not interpret any statement in this report as an official position of AHRQ or of the U. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. Workarounds to hospital electronic prescribing systems: a qualitative study in English hospitals.
The vulnerabilities of computerized physician order entry systems: a qualitative study. Outpatient CPOE orders discontinued due to 'erroneous entry': prospective survey of prescribers' explanations for errors. Patient Safety Primers.
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Please provide your feedback here:. Cancel Submit. Thus, 11 studies were eligible and received a consensus as shown in Fig. Among the excluded studies that did not meet inclusion criteria, one descriptive study provided data of post-CPOE alone [ 18 ]. Another study evaluated duplicate checks in a non-chemotherapy setting [ 19 ]. Two studies did not mention total number of prescriptions, and we were unable to retrieve the data by correspondence with the authors [ 20 , 21 ].
Two studies were comparative prospective parallel studies [ 22 , 23 ]. One prospective audit reported CPOE vs. One study compared two methods of order entry within CPOE [ 25 ]. All 11 studies were published between and and had a single-arm design in which the CPOE pre-and post-implementation phases were compared [ 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 ].
The extracted data on CME events and the study parameters are shown in Tables 1 and 2. Significant reductions in CMEs related to medical devices, adjuvants, infusion rates, and routes of administration have been documented [ 26 , 27 ].
However, in one of the included studies, there was a statistically significant increase in a specific type of CME—i. One of the studies reported complete elimination of all CMEs with adequate training and acclimatisation of personnel over a period of 5 years [ 33 ]. The average quality score of the included studies was 7. HFMEA strategies have been adopted in conjunction with CPOE with additional alerting modules for pathological conditions such as renal and liver dysfunction to execute dose modifications accordingly [ 30 ].
The maximum numbers of prescriptions were evaluated by two studies having a quality score of 8 [ 28 , 31 ]. Markert et al. The study showed that the presence of a multidisciplinary clinical service centre CSC prevented However, the incidence of serious adverse events SAEs per patient per year was reported at 7. Elsaid et al. The prescribing errors that were prevented per doses during pre-implementation, implementation, and post-implementation were Meisenberg et al.
This retrospective study involved analysing every 10th order of the handwritten and preprinted orders and every fifth order during the CPOE phase [ 32 ]. Collins et al. User satisfaction was surveyed in three studies [ 34 , 35 , 36 ]. Aziz et al. High satisfaction scores were reported for all end users by Wang et al. Chung et al. However, overall, no difference in satisfaction scores before and after CPOE was reported [ 36 ].
Three studies were prospectively designed to collect data from the prescription validation process while implementing CPOE [ 28 , 33 , 34 ], while in five studies, the data were collected as part of the routine quality assurance process and analysed retrospectively [ 26 , 29 , 30 , 31 , 32 ].
The data collection methods were not clearly explained in three studies [ 27 , 35 , 36 ]. Seven studies reported clinical implications of CPOE on the occurrence of serious or fatal events among CMEs [ 27 , 28 , 29 , 31 , 32 , 34 , 35 ].
The major, fatal, or serious adverse events SAEs that ranged from 0. Adverse events with clinical implications were completely eliminated in three studies [ 27 , 29 , 31 ]. Serious and fatal events reduced post-CPOE in another study from The total number of CMEs reported with respect to the total number of prescriptions pre- and post-CPOE implementation was collated in the meta-analysis Fig. A pooled risk ratio RR of 0. The funnel plot was asymmetrical, indicating the presence of bias due to heterogeneity among the included studies Supplementary Figure 1.
Further investigations on asymmetry were not conducted as the number of studies included in the meta-analysis was below Forest plot of the studies reporting chemotherapy related medication errors pre- and post-CPOE implementation.
X -axis represents relative risks. To our knowledge, this systematic review represents the first effort to amalgamate available data on CME occurrence pre-and post-CPOE implementation Table 1.
The beneficial effects of CPOE have been previously reported in a descriptive study [ 37 ]. Although CPOE implementation is valuable, it requires constant monitoring and training, especially during the initial implementation [ 18 , 26 ]. The study by Kim et al. The statistically significant increase in the non-matching of orders to treatment plans post-CPOE emphasised the need for proper preparation and constant surveillance, even post-CPOE [ 26 ]. Nevertheless, CPOE systems have evolved to offer solutions for such problems, e.
CPOE combined with an integrated CDSS, especially with artificial intelligence, could be an effective approach to medication safety [ 41 , 42 ].
Importantly, CDSS modules customised to chemotherapy settings should be compliant with chemotherapy protocols, dose calculations, and dose adjustments. Furthermore, they must have provisions in place for alerts at the crucial juncture of prescribing and mandatory items to ensure completeness of the prescription process [ 43 ]. The data on the impact of CPOE on clinical outcomes were included in seven studies Table 2 [ 27 , 28 , 29 , 31 , 32 , 34 , 35 ].
The magnitude of the reduction in the CMEs was translated to a reduction in adverse events, as shown by three studies where major, serious, and fatal adverse events were completely eliminated post-CPOE [ 27 , 29 , 31 ]. However, Markert et al. The harmful errors were normalised to the total orders in the report by Meisenberg et al. However, there was no proper distinction between errors and adverse reactions in the findings of Wang et al.
Thus, future studies designed to report CMEs should also include data on SAEs, which have important clinical implications. Furthermore, CPOE improved the completeness of documentation and user satisfaction in outpatient oncology settings [ 45 ]. Thus, with respect to medication safety, CPOE is a structural asset in sensitive healthcare settings, including oncology and onco-haematology units.
CPOE implementation should involve a multidisciplinary team of physicians, nurses, pharmacists, clinical pharmacologists, and information technology IT professionals. CPOE systems can eliminate MEs completely and can yield good results in an optimum time of 5 years after complete adaptation [ 33 ]. Our review should be viewed in light of the following strengths and limitations.
The included studies were from different parts of the globe; hence, the results have generalisability and applicability. Most of the studies included were single-centre studies except for one study [ 36 ], which compromised the external validity Table 1. Although single-arm designs have several limitations, they provide preliminary evidence of the effect in most scenarios. The data reported from the included studies of chemotherapy settings also included MEs from supportive care therapy, which are used along with chemotherapy.
Nevertheless, all studies used different CPOE systems and in different settings; thus, the external validity of studies should be gauged. Our meta-analysis showed high heterogeneity Fig. The high heterogeneity observed among studies limited their comparability that is commonly seen in studies reporting MEs as reported earlier [ 10 ]. Although most of the studies were poor in reporting reliability and validity measures, those excluded from meta-analysis scored poorly on study objectives, error definitions, error categories, and data collection methodologies.
However, one study showed an increase in CMEs, which was attributed to improper preparation and acclimatisation.
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