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Jin Hahn, MD
Departments of Neurology and Pediatrics,
Stanford University School of Medicine,
Stanford, CA 94305
Jill Sullivan, RN, MSN
Department of Nursing
Lucile Packard Children's Hospital,
Palo Alto, CA 94304
David Classen, MD, MS
Department of Medicine
University of Utah School of Medicine,
Salt Lake City, UT 84132
To the Editor.—
We read the article by Han et al1 with great interest. The authors of this study concluded that the implementation of computerized physician order entry (CPOE) in a pediatric critical care unit was associated with an unanticipated increase in mortality in children admitted via interfacility transport over a 5-month period. Although we acknowledge a growing concern that information technology that was intended to improve clinical care may actually facilitate certain types of errors,2,3 we are concerned that the authors' conclusion is not justified by their data.
The authors describe several critical policy changes that were implemented concurrently with CPOE, each of which could account for an increased risk of mortality in these critically ill children. First, all medications (including antibiotics and vasoactive agents) were removed from the critical care units and housed in the central pharmacy. Second, order entry was not allowed until after a transported patient had physically arrived to the hospital and was registered into the system. Finally, the pharmacy could not receive medication orders until they were activated by the patient's nurse. These all are major workflow changes that likely increased medication turnaround time for transferred patients. None of these changes were necessitated by CPOE implementation; in fact, the authors state that the second policy was rectified later, although they did not clarify whether it was done before or after the study period ended.
The authors also describe 2 critical deficiencies that are reflective of inadequate preparation for implementation of an electronic medical chart, not of CPOE per se. First was the lack of bandwidth capacity on their wireless network. This infrastructure deficiency likely contributed to decreased face-to-face interactions between the nurse and the physician when orders were being entered and highlights the important concept that CPOE is not a replacement for verbal communication. Second, the authors state in their methods section that "no ICU-specific order sets had been programmed at the time of CPOE implementation but instead were developed over time after CPOE implementation." In a consensus statement on successful CPOE implementation, Ash et al wrote that "order sets must be developed, reviewed, and maintained for personal and/or departmental usage."4 In fact, the authors later acknowledge in their discussion section that "ongoing development of preprogrammed order sets has helped to reduce some of the upfront time cost of order entry," but again, it is not clear whether this effort was made before or after the study period ended.
In summary, we believe that inadequate preparation for CPOE implementation, highlighted by inappropriate policy and process changes, insufficient infrastructure, and lack of critical care order sets, contributed substantially to the increased mortality rate reported by Han et al. We applaud the authors for highlighting the importance of careful workflow redesign in CPOE implementation, particularly in the intensive care environment, but we caution other readers not to dismiss the importance of CPOE as a tool to help prevent medical errors and enhance patient safety. Indeed, other authors from the same institution have demonstrated a hospital-wide decrease in harmful adverse drug events,5 and other studies have described decreased medical errors in both a PICU6 and an NICU7 with successful CPOE implementation.
REFERENCES
This article has been cited by other articles:
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  J. M. Walker, P. Carayon, N. Leveson, R. A. Paulus, J. Tooker, H. Chin, A. Bothe Jr., and W. F. Stewart EHR Safety: The Way Forward to Safe and Effective Systems J. Am. Med. Inform. Assoc., May 1, 2008; 15(3): 272 - 277. [Abstract] [Full Text] [PDF]
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