Madaline Kinlay1, Wu Yi Zheng2, Rosemary Burke3, Ilona Juraskova4, Rebekah Moles5, Melissa Baysari6. 1. Discipline of Biomedical Informatics and Digital Health, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia. Electronic address: mkin5770@uni.sydney.edu.au. 2. Discipline of Biomedical Informatics and Digital Health, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Black Dog Institute, Sydney, Australia. 3. Pharmacy Services, Sydney Local Health District, Sydney, Australia. 4. School of Psychology, Faculty of Science, The University of Sydney, Sydney, Australia. 5. School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia. 6. Discipline of Biomedical Informatics and Digital Health, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
Abstract
BACKGROUND: Evaluations of computerized provider order entry (CPOE) systems have revealed that reductions in certain types of medication errors occur simultaneously with the emergence of system-related errors - errors that are unlikely or not possible to occur with the use of paper-based medication charts. System-related errors appear to persist many years post-implementation of CPOE, although little is known about whether the types and rates of system-related errors that occur immediately following CPOE implementation are similar to those that endure or emerge after years of system use. OBJECTIVE: To analyze and synthesize the literature on system-related errors, specifically in relation to the length of time that CPOE systems have been in use, to determine what is currently known about how system-related errors change over time. METHODS: A literature search was undertaken using the PubMed database to identify English language articles published between January 2005 and March 2020 that provided original data on system-related errors resulting from CPOE system use. Studies were included if they provided results on system-related errors and information relating to the length of time that CPOE had been in use. RESULTS: Thirty-one studies met the inclusion criteria for this narrative review. System-related errors were identified and described during short, medium and long-term use of CPOE systems, but no single study examined how errors changed over time. In comparing findings across studies, results suggest that system-related errors persist with long-term use of CPOE systems, although likely to occur at a reduced rate. CONCLUSIONS: This review has highlighted a significant gap in knowledge on how system-related errors change over time. Determining what and when system-related errors occur and the system factors that contribute to their occurrence at different time points after CPOE implementation is necessary for the future prevention and mitigation of these errors.
BACKGROUND: Evaluations of computerized provider order entry (CPOE) systems have revealed that reductions in certain types of medication errors occur simultaneously with the emergence of system-related errors - errors that are unlikely or not possible to occur with the use of paper-based medication charts. System-related errors appear to persist many years post-implementation of CPOE, although little is known about whether the types and rates of system-related errors that occur immediately following CPOE implementation are similar to those that endure or emerge after years of system use. OBJECTIVE: To analyze and synthesize the literature on system-related errors, specifically in relation to the length of time that CPOE systems have been in use, to determine what is currently known about how system-related errors change over time. METHODS: A literature search was undertaken using the PubMed database to identify English language articles published between January 2005 and March 2020 that provided original data on system-related errors resulting from CPOE system use. Studies were included if they provided results on system-related errors and information relating to the length of time that CPOE had been in use. RESULTS: Thirty-one studies met the inclusion criteria for this narrative review. System-related errors were identified and described during short, medium and long-term use of CPOE systems, but no single study examined how errors changed over time. In comparing findings across studies, results suggest that system-related errors persist with long-term use of CPOE systems, although likely to occur at a reduced rate. CONCLUSIONS: This review has highlighted a significant gap in knowledge on how system-related errors change over time. Determining what and when system-related errors occur and the system factors that contribute to their occurrence at different time points after CPOE implementation is necessary for the future prevention and mitigation of these errors.