EFFECT OF COMPUTERIZED PHYSICIAN ORDER ENTRY AND A TEAM INTERVENTION ON PREVENTION OF SERIOUS MEDICATION ERRORS

Context.-Adverse drug events (ADEs) are a significant and costly cause of injury during hospitalization. Objectives.-To evaluate the efficac y of 2 interventions for preventing nonintercepted serious medication errors, defined as those that either resulted in or had potential to r esult in an ADE and were not intercepted before reaching the patient. Design.-Before-after comparison between phase 1 (baseline) and phase 2 (after intervention was implemented) and, within phase 2, a randomize d comparison between physican computer order entry (POE) and the combi nation of POE plus a team intervention. Setting.-Large tertiary care h ospital. Participants.-For the comparison of phase 1 and 2, all patien ts admitted to a stratified random sample of 6 medical and surgical un its in a tertiary care hospital over a 6-month period, and for the ran domized comparison during phase 2, all patients admitted to the same u nits and 2 randomly selected additional units over a subsequent 9-mont h period. Interventions.-A physician computer order entry system (POE) for all units and a team-based intervention that included changing th e role of pharmacists, implemented for half the units. Main Outcome Me asure.-Nonintercepted serious medication errors. Results.-Comparing id entical units between phases 1 and 2, nonintercepted serious medicatio n errors decreased 55%, from 10.7 events per 1000 patient-days to 4.86 events per 1000 (P=.01). The decline occurred for all stages of the m edication-use process. Preventable ADEs declined 17% from 4.69 to 3.88 (P=.37), while nonintercepted potential ADEs declined 84% from 5.99 t o 0.98 per 1000 patient-days (P=.002). When POE-only was compared with the POE plus team intervention combined, the team intervention confer red no additonal benefit over POE. Conclusions.-Physician computer ord er entry decreased the rate of nonintercepted serious medication error s by more than half, although this decrease was larger for potential A DEs than for errors that actually resulted in an ADE.