Published online November 1, 2006
PEDIATRICS Vol. 118 No. 5 November 2006, pp. 1872-1879 (doi:10.1542/peds.2006-0810)
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ARTICLE

Medication Errors Related to Computerized Order Entry for Children

Kathleen E. Walsh, MD, MSca, William G. Adams, MDb, Howard Bauchner, MDb, Robert J. Vinci, MDb, John B. Chessare, MDb,c, Maureen R. Cooper, RNb, Pamela M. Hebert, RNb, Elisabeth G. Schainker, MDd and Christopher P. Landrigan, MDe,f

a Department of Pediatrics, University of Massachusetts Medical School/University of Massachusetts Memorial Medical Center, Worcester, Massachusetts
b Department of Pediatrics, Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts
c Norwood Caritas Hospital, Norwood, Massachusetts
d Department of Pediatrics, Tufts University School of Medicine/New England Medical Center, Boston, Massachusetts
e Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
f Department of Medicine, Children's Hospital Boston, Boston, Massachusetts

OBJECTIVE. The objective of this study was to determine the frequency and types of pediatric medication errors attributable to design features of a computerized order entry system.

METHODS. A total of 352 randomly selected, inpatient, pediatric admissions were reviewed retrospectively for identification of medication errors, 3 to 12 months after implementation of computerized order entry. Errors were identified and classified by using an established, comprehensive, active surveillance method. Errors attributable to the computer system were classified according to type.

RESULTS. Among 6916 medication orders in 1930 patient-days, there were 104 pediatric medication errors, of which 71 were serious (37 serious medication errors per 1000 patient-days). Of all pediatric medication errors detected, 19% (7 serious and 13 with little potential for harm) were computer related. The rate of computer-related pediatric errors was 10 errors per 1000 patient-days, and the rate of serious computer-related pediatric errors was 3.6 errors per 1000 patient-days. The following 4 types of computer-related errors were identified: duplicate medication orders (same medication ordered twice in different concentrations of syrup, to work around computer constraints; 2 errors), drop-down menu selection errors (wrong selection from a drop-down box; 9 errors), keypad entry error (5 typed instead of 50; 1 error), and order set errors (orders selected from a pediatric order set that were not appropriate for the patient; 8 errors). In addition, 4 preventable adverse drug events in drug ordering occurred that were not considered computer-related but were not prevented by the computerized physician order entry system.

CONCLUSIONS. Serious pediatric computer-related errors are uncommon (3.6 errors per 1000 patient-days), but computer systems can introduce some new pediatric medication errors that are not typically seen in a paper ordering system.

Key Words: computerized physician order entry • medication errors • hospital performance • patient safety • computer order entry

Abbreviations: CPOE—computerized physician order entry • CRE—computer-related error • CI—confidence interval

Accepted Jun 27, 2006.




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