EHR-Based CPOE Tools Miss Many Dangerous Medication Interactions

Hospital EHRs frequently miss harmful or potentially fatal errors, according to a study published in the journal JAMA Network Open.

To conduct the study, researchers analyzed 8,657 observations using the National Quality Forum Health IT Safety Measure, a CPOE and EHR safety test administered by the Leapfrog Group between 2009 and 2018. The tool uses simulated drug orders that have either injured or killed patients in the past.

The CPOE EHR evaluation tool, which was designed by investigators at the University of Utah and the Brigham and Women’s Hospital, is included as part of the Leapfrog hospital survey.

The study breaks the order types into potential adverse events that could be blocked by basic clinical decision support tools such as therapeutic duplication contraindications, and problems which called for advanced CDS, such as drug-diagnosis and drug-dose issues. Researchers looked at whether the CPOE EHR system generated an alert, a warning, or a soft or hard stop when orders that could lead to an adverse drug event were entered.

During the period studied, mean scores on the overall test climbed from 53.9% in 2009 to 65.6% in 2018, which leaves out approximately one-third of hospitals.

The mean scores reflect the extent to which hospitals are meeting basic safety standards, which include having physicians working in inpatient settings enter medication orders via a system linked to a prescribing error prevention software, demonstrating that their CPOE system can intercept at least 50% of common serious prescribing errors and requiring documented acknowledgment of intercepts prior to any override.

Meanwhile, mean hospital scores for categories tracking basic clinical decision support went up from 69.8% to 85.6%. For categories involving advanced clinical decision support, mean scores increased from 29.6% to 46.1%.

The highest-performing category was drug-allergy in each year, which grew from 92.9% in 2009 to 98.4% in 2018. The lowest-performing category was drug-diagnosis counterindications, which had a mean score of 20.4% and rose to 33.2%.

The researchers noted that despite the optimization of EHRs in hospitals, there is still a great deal of variation in the safety performance of such systems. This suggests that EHR CPOE systems still have serious safety vulnerabilities.

The study didn’t look at the performance of independent CPOE systems but focused entirely on those integrated with the hospital EHR.  In other words, it didn’t offer any perspective on whether freestanding independent systems were performing better than those integrated with EHRs However, my guess is they face some serious flaws as well.

Given that many hospitals still rely on EHR-based CPOE systems provided by the system’s vendor, it’s troubling to hear that patients could be at such risk. The current level of dangerous medication errors which are apparently slipping through the cracks is unacceptable.

About the author

Anne Zieger

Anne Zieger

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.