Increased Mortality after CPOE Implementation

The December 2005 issue of the journal Pediatrics has a report that found a coincident increase in mortality after implementing a ‘Commercially Sold’ Computerized Physician Order Entry (CPOE) system. The increased mortality may have been due to delays in medication and IV administration in the ICU caused by the new system: ‘…Although CPOE technology holds great promise as a tool to reduce human error during health care delivery our unanticipated finding suggests that when implementing CPOE systems, institutions should continue to evaluate mortality effects, in addition to medication error rates, for children who are dependent on time-sensitive therapies.’ The study notes that mortality rate studies on CPOE as opposed to adverse drug events(ADEs) studies has not been done before. The CPOE in the study DID reduce ADE’s as expected.

In this case, the software system was Cerner PowerOrders. As the study notes ‘…no ICU-specific order sets had been programmed at the time of CPOE implementation, but instead were developed over time after CPOE implementation.’

This was a retrospective study over an 18 month period from October 1, 2001, to March 31, 2003. ‘…Among 1942 children who were referred and admitted…75 died…Mortality rate significant increased from 2.8% (39 of 1394) before CPOE implementation to 6.57% (36 of 548) after CPOE implementation…’ The authors note that ‘…our observation period after CPOE implementation was brief and may simply reflect the adjustment period that commonly follows any major, sweeping change. It is possible that had we extended our study another quarter…’

Thanks to Scot Silverstein for this link.

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