Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: a systematic review and meta-analysis

Objective: To conduct a systematic review and meta-analysis of the impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay (LOS), and mortality in intensive care units (ICUs). Methods: We searched for English-language literature published between January 2000 and January 2016 using Medline, Embase, and CINAHL. Titles and abstracts of 586 unique citations were screened. Studies were included if they: (1) reported results for an ICU population; (2) evaluated the impact of CPOE or the addition of CDSSs to an existing CPOE system; (3) reported quantitative data on medication errors, ICU LOS, hospital LOS, ICU mortality, and/or hospital mortality; and (4) used a randomized controlled trial or quasi-experimental study design. Results: Twenty studies met our inclusion criteria. The transition from paper-based ordering to commercial CPOE systems in ICUs was associated with an 85% reduction in medication prescribing error rates and a 12% reduction in ICU mortality rates. Overall meta-analyses of LOS and hospital mortality did not demonstrate a significant change. Discussion and Conclusion: Critical care settings, both adult and pediatric, involve unique complexities, making them vulnerable to medication errors and adverse patient outcomes. The currently limited evidence base requires research that has sufficient statistical power to identify the true effect of CPOE implementation. There is also a critical need to understand the nature of errors arising post-CPOE and how the addition of CDSSs can be used to provide greater benefit to delivering safe and effective patient care.

[1]  Enrico W. Coiera,et al.  Application of Information Technology: Handheld Computer-based Decision Support Reduces Patient Length of Stay and Antibiotic Prescribing in Critical Care , 2005, J. Am. Medical Informatics Assoc..

[2]  F. Song,et al.  Evaluating non-randomised intervention studies. , 2003, Health technology assessment.

[3]  G. Kadmon,et al.  Computerized Order Entry With Limited Decision Support to Prevent Prescription Errors in a PICU , 2009, Pediatrics.

[4]  D. Bates,et al.  Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. , 2003, Archives of internal medicine.

[5]  D. Bates,et al.  Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units. , 1997, Critical care medicine.

[6]  Hasan M. Al-Dorzi,et al.  Impact of computerized physician order entry (CPOE) system on the outcome of critically ill adult patients: a before-after study , 2011, BMC Medical Informatics Decis. Mak..

[7]  L. Cordero,et al.  Impact of Computerized Physician Order Entry on Clinical Practice in a Newborn Intensive Care Unit , 2004, Journal of Perinatology.

[8]  J. Braithwaite,et al.  Effects of Two Commercial Electronic Prescribing Systems on Prescribing Error Rates in Hospital In-Patients: A Before and After Study , 2012, PLoS medicine.

[9]  James D. Carpenter,et al.  Categorizing the unintended sociotechnical consequences of computerized provider order entry , 2007, Int. J. Medical Informatics.

[10]  O. Gajic,et al.  The addition of decision support into computerized physician order entry reduces red blood cell transfusion resource utilization in the intensive care unit , 2007, American journal of hematology.

[11]  Kirsten Colpaert,et al.  Impact of computerized physician order entry on medication prescription errors in the intensive care unit: a controlled cross-sectional trial , 2006, Critical care.

[12]  I. Hozo,et al.  Estimating the mean and variance from the median, range, and the size of a sample , 2005, BMC medical research methodology.

[13]  Eric Widen,et al.  Embedding Time-Limited Laboratory Orders Within Computerized Provider Order Entry Reduces Laboratory Utilization* , 2013, Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.

[14]  H. Stelfox,et al.  Clinical review: Medication errors in critical care , 2008, Critical care.

[15]  P. Shekelle,et al.  The effectiveness of computerized order entry at reducing preventable adverse drug events and medication errors in hospital settings: a systematic review and meta-analysis , 2014, Systematic Reviews.

[16]  Vimla L. Patel,et al.  Anticipating and addressing the unintended consequences of health IT and policy: a report from the AMIA 2009 Health Policy Meeting , 2011, J. Am. Medical Informatics Assoc..

[17]  Adam B. Keene,et al.  Mortality before and after initiation of a computerized physician order entry system in a critically ill pediatric population* , 2007, Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.

[18]  Eric Widen,et al.  Computerized Physician Order Entry With Decision Support Decreases Blood Transfusions in Children , 2011, Pediatrics.

[19]  G. Nuttall,et al.  Evidence-based red cell transfusion in the critically ill: Quality improvement using computerized physician order entry* , 2006, Critical care medicine.

[20]  J. Sterne,et al.  How important are comprehensive literature searches and the assessment of trial quality in systematic reviews? Empirical study. , 2003, Health technology assessment.

[21]  Jennifer Lai,et al.  Unintended Consequences of Information Technologies in Health Care—An Interactive Sociotechnical Analysis , 2007 .

[22]  Matthew F. Niedner,et al.  Increasing medication error reporting rates while reducing harm through simultaneous cultural and system-level interventions in an intensive care unit , 2011, BMJ quality & safety.

[23]  A. Egberts,et al.  The Effect of Computerized Physician Order Entry on Medication Prescription Errors and Clinical Outcome in Pediatric and Intensive Care: A Systematic Review , 2009, Pediatrics.

[24]  D. Bates,et al.  Finding the meaning in meaningful use. , 2011, The New England journal of medicine.

[25]  Y. Han,et al.  Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry System , 2005, Pediatrics.

[26]  ELSKE AMMENWERTH,et al.  Review Paper: The Effect of Electronic Prescribing on Medication Errors and Adverse Drug Events: A Systematic Review , 2008, J. Am. Medical Informatics Assoc..

[27]  C. Longhurst,et al.  Decrease in Hospital-wide Mortality Rate After Implementation of a Commercially Sold Computerized Physician Order Entry System , 2010, Pediatrics.

[28]  D. Bates,et al.  The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive care* , 2005, Critical care medicine.

[29]  B. Franklin,et al.  A clinical information system reduces medication errors in paediatric intensive care , 2011, Intensive Care Medicine.

[30]  Andrew Georgiou,et al.  The effect of computerized provider order entry systems on clinical care and work processes in emergency departments: a systematic review of the quantitative literature. , 2013, Annals of emergency medicine.

[31]  R Core Team,et al.  R: A language and environment for statistical computing. , 2014 .

[32]  Chad D. Meyerhoefer,et al.  “Reducing unnecessary testing in a CPOE system through implementation of a targeted CDS intervention” , 2013, BMC Medical Informatics and Decision Making.

[33]  D. Classen,et al.  Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality. , 1997, JAMA.

[34]  Brian A. Nosek,et al.  Power failure: why small sample size undermines the reliability of neuroscience , 2013, Nature Reviews Neuroscience.

[35]  Jose Lopez-Sendon,et al.  Computerized physician order entry in the cardiac intensive care unit: effects on prescription errors and workflow conditions. , 2014, Journal of critical care.

[36]  Brian W. Pickering,et al.  Impact of the Electronic Medical Record on Mortality, Length of Stay, and Cost in the Hospital and ICU: A Systematic Review and Metaanalysis* , 2015, Critical care medicine.

[37]  P. Aspden,et al.  Preventing Medication Errors , 2007 .

[38]  Matthew A. Eisenberg,et al.  Computerized Provider Order Entry Implementation: No Association With Increased Mortality Rates in an Intensive Care Unit , 2006, Pediatrics.

[39]  P. Dodek,et al.  Computerized physician order entry of diagnostic tests in an intensive care unit is associated with improved timeliness of service , 2004, Critical care medicine.

[40]  Catherine Yoon,et al.  The costs of adverse drug events in community hospitals. , 2012, Joint Commission journal on quality and patient safety.

[41]  D. Moher,et al.  Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. , 2010, International journal of surgery.

[42]  M. Singer,et al.  Medication errors: a prospective cohort study of hand-written and computerised physician order entry in the intensive care unit , 2005, Critical care.

[43]  Johanna I Westbrook,et al.  Review Paper: Does Computerized Provider Order Entry Reduce Prescribing Errors for Hospital Inpatients? A Systematic Review , 2009, J. Am. Medical Informatics Assoc..

[44]  D. Altman,et al.  Measuring inconsistency in meta-analyses , 2003, BMJ : British Medical Journal.

[45]  L Barrow,et al.  The impact of computerised physician order entry on prescribing practices in a cardiothoracic intensive care unit * , 2010, Anaesthesia.

[46]  G. Smith,et al.  Bias in meta-analysis detected by a simple, graphical test , 1997, BMJ.

[47]  A. Potts,et al.  Computerized physician order entry and medication errors in a pediatric critical care unit. , 2004, Pediatrics.

[48]  Joan,et al.  Clinical Decision Support Capabilities of Commercially-available Clinical Information Systems , 2022 .

[49]  Guido Knapp,et al.  Improved tests for a random effects meta‐regression with a single covariate , 2003, Statistics in medicine.

[50]  Ling Li,et al.  The safety of electronic prescribing: manifestations, mechanisms, and rates of system-related errors associated with two commercial systems in hospitals , 2013, J. Am. Medical Informatics Assoc..

[51]  W. K. Kennedy,et al.  Computerized Prescriber Order Entry and Opportunities for Medication Errors , 2013, Journal of pharmacy practice.