D219 Task 1: Addressing Medication Errors with CPOE Systems

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Western Governors University

D218 Intrapersonal Leadership and Professional Growth

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Date

Clinical Practice Problem: Medication Errors in Hospitals

Medication errors remain a significant challenge in hospital environments, posing severe risks to patient health and organizational efficiency. Patients affected by such errors may suffer from adverse drug reactions, prolonged hospital stays, or even life-threatening complications, which can diminish their trust in the healthcare system. From an institutional perspective, these incidents can lead to financial losses through legal claims, reputational damage, and increased operational costs due to extended patient stays and additional treatments. Moreover, repeated errors often contribute to healthcare provider burnout and decreased morale.

The integration of Computerized Physician Order Entry (CPOE) systems has been recognized as an effective approach to minimizing medication errors. These systems allow physicians to enter medication orders electronically, which helps reduce human-related mistakes such as transcription errors or misinterpretations of handwritten prescriptions. Compared to traditional manual processes, CPOE systems support accuracy, enhance communication among healthcare teams, and ultimately improve patient safety and healthcare outcomes (Collins et al., 2021; Elsaid et al., 2020).

PICO Components of Medication Errors in Hospitals

PICO Element	Description	Supporting Literature
P (Patient/Population/Problem)	Hospitalized patients experiencing or at risk of medication errors such as incorrect drug, dosage, or timing.	Collins et al. (2021); Elsaid et al. (2020)
I (Intervention)	Implementation of a Computerized Physician Order Entry (CPOE) system with integrated clinical decision support tools.	Collins et al. (2021)
C (Comparison)	Traditional manual prescription methods involving handwritten or basic digital orders without decision support.	Elsaid et al. (2020)
O (Outcome)	Reduction in medication errors and adverse drug events, leading to enhanced patient safety and improved quality of care.	Collins et al. (2021); Elsaid et al. (2020)

Evidence-Based Practice (EBP) Question

For hospitalized patients, does the use of a Computerized Physician Order Entry (CPOE) system with medical decision support, compared to traditional manual medication ordering, result in fewer medication errors and improved patient safety?

Background/Introduction

The article “Effects of CPOE-based medication ordering on outcomes: An overview of systematic reviews” explores the impact of CPOE systems on hospital medication safety. Abraham et al. (2020) synthesized findings from multiple systematic reviews to evaluate the overall effectiveness of CPOE systems in reducing medication-related errors and improving patient outcomes. The study acknowledges that while CPOE adoption is widespread, results vary, emphasizing the importance of system design, implementation strategies, and user training in maximizing safety benefits.

Research Methodology

The researchers conducted a systematic review of seven systematic reviews, encompassing 118 primary studies. These studies collectively assessed outcomes such as medication errors, adverse drug reactions, and patient mortality. Rigorous inclusion criteria, data extraction procedures, and multi-reviewer quality assessments ensured a high degree of validity and reliability (Abraham et al., 2020).

Level of Evidence Using the JHNEBP Model

According to the Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model, this study represents Level I evidence, the highest level in the hierarchy. Systematic reviews provide comprehensive, synthesized data across numerous studies, delivering reliable conclusions on the effectiveness of CPOE systems in enhancing patient safety (Abraham et al., 2020; Johns Hopkins Medicine, 2022).

Summary of Data Analysis

Abraham et al. (2020) conducted a meta-analysis by integrating the outcomes from seven systematic reviews. Using statistical models, they measured risk reduction levels across multiple healthcare environments. Variables such as study quality, outcome definition, and control group design were carefully evaluated. Their analysis revealed consistent evidence that CPOE systems significantly reduce medication errors and adverse drug events. However, improvements in overall patient mortality and length of hospital stay were less consistent, suggesting that while CPOE enhances safety, complementary interventions may be required to influence broader health outcomes.

Ethical Considerations

Since the study was a systematic review, no direct interaction with human participants occurred. Ethical responsibility centered on ensuring accurate synthesis and unbiased interpretation of existing data. All included studies had obtained prior ethical approvals. The authors maintained transparency and avoided selective reporting to ensure the integrity of the meta-analysis (Abraham et al., 2020).

Quality Rating According to JHNEBP

Using the JHNEBP model, the article is rated as “A” quality evidence due to its robust methodology, clear data synthesis, and consistent findings. The systematic review format ensures comprehensive coverage and minimizes researcher bias, making it a strong foundation for clinical decision-making (Johns Hopkins Medicine, 2022).

Results Analysis

The findings confirmed that CPOE systems substantially reduce medication errors and adverse drug events within hospitals. The magnitude of improvement varies based on system configuration, training effectiveness, and user adherence. While improvements in patient mortality were inconclusive, the consistent reduction in prescription-related errors supports CPOE as a critical strategy in enhancing medication safety (Abraham et al., 2020).

Non-Research-Based Evidence

Background/Introduction

The narrative review “Medication Errors Related to Computerized Provider Order Entry Systems in Hospitals and How They Change Over Time” by Kinlay et al. (2021) examines how CPOE systems evolve and influence error rates post-implementation. Although these systems aim to enhance patient safety, the authors note that CPOE may introduce new types of errors, especially during early adoption. The article provides strategies to mitigate such risks and ensure sustainable improvements in medication safety.

Types and Level of Evidence

This narrative review draws from existing literature, expert opinions, and clinical experiences, rather than primary data. According to the JHNEBP model, it is classified as Level V evidence, which, while not empirical, provides valuable context and practical recommendations based on observed patterns and lessons from previous studies (Johns Hopkins Medicine, 2022).

Quality Rating

The article receives a “B” quality rating under the JHNEBP model. It is well-organized and insightful but lacks the rigor of experimental or systematic review research. Nonetheless, it offers practical implications for hospitals implementing or refining CPOE systems (Kinlay et al., 2021).

Author’s Recommendations

Kinlay et al. (2021) emphasize that while CPOE systems minimize errors linked to poor handwriting or omitted doses, improper implementation or inadequate training can generate new challenges. For example, if clinicians misinterpret automated alerts or enter incorrect data, errors may still occur. Thus, hospitals should focus on continuous staff education, system updates, and customization to their specific workflows. Proper integration with electronic health records (EHR) and feedback-driven refinement are essential to optimize the CPOE system’s safety benefits.

Recommended Practice Changes

Involving Key Stakeholders

Effective CPOE implementation requires collaboration among three major stakeholder groups:

Stakeholder	Role and Contribution
Healthcare Providers (Physicians, Nurses, Pharmacists)	Primary users of the CPOE system; provide feedback and ensure proper utilization.
IT Support Team	Manages system setup, integration, and ongoing technical support.
Hospital Administration	Allocates resources, approves budgets, and aligns CPOE use with institutional safety goals.

Engaging all three groups ensures system acceptance, technical stability, and institutional alignment with safety objectives.

Identified Barrier

A potential barrier involves resistance from healthcare staff accustomed to manual prescription methods. Concerns may arise regarding workflow disruptions, system complexity, and lack of familiarity with the technology.

Strategy to Overcome the Barrier

A structured training and support initiative should be implemented, including simulations, workshops, and hands-on training. The appointment of “superusers”—staff members proficient in CPOE operation—can support peers during the transition. Regular refresher sessions and visible reporting of medication error reductions can reinforce system value and improve user confidence (Kinlay et al., 2021).

Outcome Evaluation

The primary outcome measure is the reduction in medication error rates post-CPOE implementation. Tracking pre- and post-intervention data will determine the system’s effectiveness. Continuous monitoring through quality improvement committees can sustain long-term success and enhance patient safety culture (Kinlay et al., 2021).

References

Abraham, J., Kitsiou, S., Meng, A., & Vatani, H. (2020). Effects of CPOE-based medication ordering on outcomes: An overview of systematic reviews. BMJ Quality & Safety, 29(10), 854–863. https://doi.org/10.1136/bmjqs-2019-010436

Collins, C. M., Elsaid, K. A., Markert, J. M., & Meisenberg, B. R. (2021). Impact of computerized physician order entry (CPOE) on the incidence of chemotherapy-related medication errors: A systematic review. European Journal of Clinical Pharmacology, 77(4), 487–497. https://doi.org/10.1007/s00228-020-03046-1

Elsaid, K. A., Collins, C. M., Markert, J. M., & Meisenberg, B. R. (2020). Impact of CPOE systems on medication errors in hospitals: A systematic review. Journal of the American Medical Informatics Association, 28(1), 167–176. https://doi.org/10.1093/jamia/ocaa223