It was an innocent mistake-something you read about and wonder about from time to time-yet an error you'd never expect would happen in your own practice. In my field of medical informatics, I have
studied the literature and know that medication errors are common and occur more frequently than we, as a profession, might care to admit.
Yet it was a surprise when it happened to me, in my own academic practice at a top-notch university medical center. I think about it to this day, and it's one of the reasons I believe we clinicians must adopt computer-based provider order entry (CPOE) technology to better our practices and ultimately improve the quality of care for our patients.
The patient was a 55-year-old woman with a diagnosis of chronic paranoid schizophrenia and hypertension. She was doing pretty well in the course of her routine care: no tardive dyskinesias, good blood-pressure control, living independently.
My nurse, with whom I had worked for years, gave me prescriptions to sign when the patient came in for refills. The nurse had filled them out for me-not our usual practice, but we had been busy that day-and it was late. So I looked them over, signed them and gave the patient a prescription for Stelazine 200mg po q d.
It should have been for 20mg po q d.
Regrettably, situations like this are now known to occur regularly in hospital and outpatient care settings. We know that medication errors occur in as many as one in 20 admissions. In the outpatient environment, as many as 9% of prescriptions may include an error of some kind: wrong medication, wrong dose, wrong route, wrong frequency or incomplete Rx. It is likely that the situation is comparable in other academic settings and may be similar in community outpatient settings.
Using a computer in clinical practice can help prevent many types of medication errors and improve the quality of care as well. We know that using a computer system when writing a prescription can help ensure the prescription is complete and legible; that the medication dose, route and frequency are appropriate; that, if a dosing calculation must be made, it will be correct; that allergic reactions are avoided; that interactions with other drugs the patient is taking are avoided; and that patients don't receive more drug than they should (cumulative dose ceilings, or LD50).
And when the patient's health plan has a restricted formulary, the computer can check to be sure the drug you want to prescribe is on the formulary, or it can suggest a covered alternative.
Using a computer when writing other orders can also be of benefit. Sophisticated order-entry systems can check what orders are outstanding for a patient, avoid duplicate laboratory tests and procedures and show the costs of tests to the clinician.
They may also help increase adherence to disease management guidelines, suggest appropriate diagnostic radiology examinations, and provide alerts and reminders for healthcare maintenance and preventive care such as screening tests and wellness programs.
The most sophisticated systems fit well into the clinical work flow and can help ensure complete charge capture, documentation of medical diagnoses and procedures, and medical-necessity indications for tests and procedures from an electronic record.
Using these systems in clinical practice is a change from the past, but it is one that is absolutely necessary to allow us to be the best clinicians we can possibly be and ultimately bring the best evidence from medical research to bear on every one of our clinical decisions. The computer is the single most important technology in the clinical armamentarium today. As the stethoscope is to our ability to auscultate the body, the computer is to clinical decision making.
My patient did OK, even though I thought I might not survive that medical error myself. She seemed to weather the extra medication tolerably well, and we corrected her prescription.
Our hospital has had inpatient CPOE since the mid-1990s, and we are installing our homegrown Longitudinal Medical Record (our moniker for the EMR) with CPOE through all our ambulatory clinics. This Web-based product costs each physician approximately $12,900 for software, hardware, network and implementation.
Most physicians can't wait to get it into their clinics because, despite the small hassles of logging on and typing orders, they are confident they are providing higher-quality care. And our research has shown a positive ROI over five years for our EMR (IRR = 152%).
Our work at the Center for Information Technology Leadership has focused on rigorously analyzing and generalizing the costs and benefits for CPOE in ambulatory care, and the results are clear: Ambulatory CPOE has a dramatic effect on improving the quality of care, reducing unnecessary costs and even improving clinical revenue.
In CPOE, we now have the technology to reduce these types of errors every time we write an order. We wouldn't practice without a stethoscope, and we should be using CPOE in all care settings today.
Blackford Middleton, M.D., is chairman of the Center for Information Technology Leadership, Partners Healthcare, Boston.