Errors Related to CPOE

Electronic health records (EHRs) and computer-based provider order entry (CPOE) systems were developed in part to reduce the risk of injury to patients. Their potential to increase the quality and safety of care is well documented but concerns remain about the consequences of poor design, implementation or inadequate adaptation to established practices and realities of clinical work. This case study describes a potassium chloride overdose in a hospitalized patient that occurred despite the use of electronic ordering. Several important aspects of the serious adverse event were in fact attributable to failures in interaction with a system that had many design and functional characteristics inconsistent with common usability conventions and principles of cognitive engineering. Cognitive errors with the potential to engender adverse events may occur relatively frequently when complex information technology is used routinely in safety-critical work environments. The risk of a certain type of error can be effectively reduced by employing safe design practices during software development, while others can be addressed during implementation and by monitoring and periodic evaluation of critical processes under normal working conditions.