Despite Improvement, New Report Reveals Technology to Prevent Medication Errors Fails Too Often

April 9, 2015

Nonprofit hospital watchdog The Leapfrog Group today released its report on Computerized Physician Order Entry (CPOE) Systems and Medication Errors, which shows a record number of U.S. hospitals are using technology to reduce potential medication prescribing errors; however, these systems fail too often, jeopardizing patients’ safety. The results, as analyzed by Castlight Health, demonstrate that some U.S. hospitals are better at preventing medication errors, the leading cause of harm to patients.

The in-depth examination looked at the use of CPOE systems by hospital clinicians, who directly enter medication orders into a computer system and electronically transmit them to a pharmacy. Medication errors are the most common mistakes made in hospitals. In fact, each year, serious, preventable medication errors affect 3.8 million patients. Errors such as dosing, drug allergies, harmful drug interactions or dispensing problems are frequent, and the harm they cause can be significant, even resulting in death. As nearly 90 percent of medication errors occur during manual ordering and transcribing, effective use of CPOE systems can help reduce the risk of the wrong drug or dose being delivered to a patient.


Key Report Findings include:

  • Increased CPOE System Use: In 2014, an all-time record of 1,339 hospitals reported using a CPOE system in at least one inpatient unit, compared with only 384 hospitals in 2010. Fifty-nine percent of hospitals entered at least 75 percent of all medication orders electronically in 2014.
  • Increased CPOE System Testing: In 2014, hospitals performed more than 1,200 simulation tests using Leapfrog’s CPOE Evaluation Tool, developed by Dr. David Bates, Dr. David Classen and Jane Metzger, to examine their system’s effectiveness. That’s a 30 percent increase over 2013.
  • However, Technology Failure Rates Remain Too High: Despite the increase in testing, performance hasn’t improved. In both 2013 and 2014, the rate of potentially harmful medication orders entered that did not receive an appropriate warning remained at 36 percent. Furthermore, the number of potentially fatal medication orders that weren’t flagged remained too high, at 13.9 percent.

“Hospitals should not assume that putting CPOE in place automatically means their medication program is safe. On the contrary, while CPOE helps prevent errors, it is imperfect and hospitals need to keep in place the checks and double-checks to make sure patients are not given the wrong medication,” said Leah Binder, president & CEO of Leapfrog. “Hospitals that take the simulation test can learn important information about gaps in their medication safety and fix them. We are pleased that so many hospitals participated in the simulation. Their patients are safer as a result of that leadership.”

“Not only are medication errors dangerous, but these preventable incidents are expensive. Each error is estimated to cost nearly $4,300, or nearly $16.4 billion dollars annually,” said Jennifer Schneider, M.D., M.S., Chief Medical Officer for Castlight Health.

The complete report on CPOE and Medication Errors is available here

Today’s report is the third in a series of six reports examining key quality and safety measures at hospitals nationwide, based on data taken from the 2014 Leapfrog Hospital Survey of 1,501 U.S. hospitals and analyzed by Castlight Health. The initial reports on maternity care and high-risk procedures, as well as future publications in the report series, are also available.


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