Report: CPOE Systems Failed to Flag 13 Percent of Potentially Fatal Medication Orders

Oct. 5, 2016
In conjunction with Medication Safety Awareness Week, the Leapfrog Group released a report this week that found hospitals’ computerized physician order entry (COPE) systems are not operating as well as they should and failed to flag potentially harmful or even fatal medication errors.

In conjunction with Medication Safety Awareness Week, the Leapfrog Group released a report this week that found hospitals’ computerized physician order entry (COPE) systems are not operating as well as they should and failed to flag potentially harmful or even fatal medication errors.

The report, Preventing Medication Errors in Hospitals, analyzes data The Leapfrog Group collected from 1,750 U.S. hospitals last year as part of its 2015 Leapfrog Hospital Survey that examines key quality and safety measures. The Leapfrog Group is a Washington, D.C.-based nonprofit organization representing consumers, employers and other purchasers focused on improving healthcare safety and quality. Castlight Health analyzed the data collected.

Studies have shown that CPOE systems are a remarkably effective health IT tool for reducing the rate of serious medication errors. However, the 2015 Leapfrog Hospital Survey indicated that hospitals’ CPOE systems failed to flag 39 percent of all potentially harmful drug orders, or nearly two out of every five orders. And, the systems also missed 13 percent of potentially fatal medication orders.

“I think the most surprising and disturbing finding is that of the hospitals that participated in our survey and did the CPOE evaluation tool, 13 percent of potentially fatal medication orders were not caught by CPOE systems, so that’s just about one in seven patients is potentially subject to a potential fatal medication error,” Erica Mobley, Leapfrog’s director of communications and development, says. “This points to the need for patients to consider these issues when choosing a hospital. Patients should look for a hospital that has a CPOE system in place to prevent medication errors, and patients should use our results and ratings to find a hospital that has a proven record of having the systems in place to better prevent medication errors.”

Medication errors are the most common errors that happen in the hospital, Mobley says, and studies have shown that one in 20 hospital patients has experienced an adverse drug event (ADE). Adverse drug events can result in a longer hospital stay and increased costs averaging $3,000 per patient, the report stated.

The good news is that there has been rapid adoption of CPOE systems among U.S. hospitals in the past few years, spurred in part by federal investment in hospital IT infrastructure. The report found that almost every reporting hospital (96 percent of surveyed hospitals) reported adoption of a CPOE system, and that’s up from just 33 percent in 2010 and just two percent when Leapfrog began reporting on CPOE in 2001, the report stated. However, that means 4 percent of hospitals have yet to implement a CPOE system.

The report cites a study led by David Bates, M.D., chief of general medicine at Boston’s Brigham and Women’s Hospital, that found that the use of CPOE systems reduced error rates by 55 percent—from 10.7 to 4.9 per 1,000 patient days. Rates of serious medication errors fell by 88 percent in a subsequent study by the same group. And, the report states that research estimates that implementation of CPOE system at all non-rural U.S. hospitals could prevent three million adverse drug events a year.

CPOE systems allow physicians to input medication instructions into a computer system that can access patient information such as allergies, existing medications, and lab results. The system checks the prescription order to check for any potential problems.

“CPOE systems have done a remarkable job in reducing the likelihood of medication errors, but mistakes are still seen with far too much frequency,” Leah Binder, president and CEO of Leapfrog, said in a statement. “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.”

Back in 2001, Leapfrog developed a CPOE evaluation tool in collaboration with leading academic researchers that enables hospitals to test their systems. As part of the 2015 hospital survey, hospitals used the evaluation tool which invovles entering simulated patient data into their CPOE systems. The hospitals were then given a list of orders—some containing potentially harmful or even fatal error—to run through their CPOE systems.

The most common unflagged errors related to medications or dosage include:

  • Diagnosis (e.g., prescribing a beta blocker to a patient with asthma)
  • Kidney function (e.g., a drug that must be processed by the kidneys given to a patient with impaired  kidney function without reducing the dose accordingly)
  • Monitoring (e.g., the failure to display a reminder to test drug levels after issuing a medication, when such follow-up is clinically indicated).

“Hospitals’ ability to correctly flag potential errors has improved only slightly (one percentage point) since 2014. Without accelerated improvement, patients will continue to receive medications or dosages that increase their risk of injury or death,” the report stated.

Mobley said hospitals should annually test their CPOE systems. “Use of the Leapfrog CPOE evaluation tool enables hospitals to make sure their systems are catching the errors that the systems are designed to and that they are getting their money’s worth. If they find that the system is not working as it should, then they can make adjustments so that more potential medication errors are caught before those mediations are inadvertently administered to patients,” she says.

Leapfrog also developed a standard for CPOE implementation and quality. 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 place at least 75 percent of inpatient medication orders through a CPOE system.

The survey found that nearly two-thirds of hospitals (64 percent) fully met these standards. State-by-state comparisons also show where use and effectiveness of CPOE is lacking. Among the states with the lowest percentage of hospitals meeting Leapfrog’s standard were Indiana (25 percent) and Nevada (35 percent). Five other states also had fewer than 50 percent of hospitals meeting the standard. Among the states with the most hospitals meeting the standard were Maine (85 percent), Georgia (83 percent), and New York (81 percent). In addition, there were eight other states that had 75 percent or more hospitals meeting the standard.

The survey also found that hospitals are implementing process and procedure improvements to prevent adverse drug events.

In a series of 15 questions based on the National Quality Forum’s Safe Practices for Better Healthcare, hospitals were asked to report on efforts to implement policies and procedures that can prevent adverse drug events. Over half (62 percent) of reporting hospitals indicated they conduct all recommended medication reconciliation activities. Nearly all hospitals had implemented processes for documenting patient medications at admission (98 percent) and shared the updated medication list with patients and caregivers at discharge (99 percent).

However, the report found that not all hospitals had implemented the policies to ensure adherence to these processes. Only 84 percent of hospitals held their senior administrative leadership accountable for these processes through their performance review of compensation. What’s more, only 88 percent hospitals had staff time or a budget allocated to developing best practices.

"It is critical that hospitals maintain well-functioning CPOE systems and proper accompanying manual reviews to ensure patients receive the best possible care,” Kristin Torres Mowat, senior vice president of plan development and data operations at Castlight Health., said in a statement.

Mobley also says CPOE vendors should proactively make improvements to their systems.

“When a hospital implements a CPOE system, there is a lot of customization that happens to adapt to that hospital’s drug formulary, and I think that vendors could be working more closely with the hospitals to make sure that customization is being done effectively. Vendors also could encourage hospitals to participate in the CPOE evaluation that we offer to see how well their systems are working. If the hospital does not do well and medication errors are not flagged, the vendors could use the results from the tool to make improvements to the system as needed,” she says.