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PSNet: Patient Safety Network
Journal Article

Prescription errors and outcomes related to inconsistent information transmitted through computerized order entry: a prospective study.

Singh H, Mani S, Espadas D, et al. Archives of internal medicine. 2009;169:982-9.

Computerized provider order entry (CPOE) effectively prevents actual and potential medication errors, but a growing body of research has characterized new errors that may occur after implementation of CPOE. A new type of error is characterized in this study, in which investigators examined inconsistencies between CPOE order templates and free-text fields within the system. Approximately 1% of orders contained inconsistencies, usually relating to drug dosing. These inconsistencies had high potential for causing adverse drug events, as many occurred in orders for high-risk medications. This study reinforces the importance of integrating CPOE systems with provider workflow.