Computerized order system linked with increased pediatric mortality [Pediatrics Classics Series]

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1. The use of a computerized physician order entry (CPOE) program in a large, tertiary pediatric hospital was associated with over 3 times increased risk of mortality when compared to patients admitted to the same center prior to CPOE implementation.

2. CPOE implementation resulted in increased physician time placing medication orders as opposed to providing patient care and delays in medication administration as medications now were located in the hospital pharmacy, not at the bedside.

Original Date of Publication: December 2005

Study Rundown: Computerized physician order entry (CPOE) systems were initially implemented to aid in reducing the tens of thousands of medical errors contributing to patient deaths across the United States. In 2002, the implementation of a CPOE in one large, tertiary pediatric hospital resulted in significant decreases in adverse drug events (ADEs); however, questions regarding patient outcomes and unintended consequences arose, a topic few studies had investigated. This study was one of the first to evaluate long-term outcomes following CPOE implementation by examining mortality rates among children admitted to the same facility from the 2002 study. Retrospective analysis comparing patients transferred to the hospital before and after CPOE administration revealed a significant increase in mortality risk associated with care post-CPOE. Researchers attributed this result to changes in patient care following the implementation including increased physician time spent entering orders and new challenges in acquiring medications as drugs now needed to be located in the hospital pharmacy as opposed to at the bedside. This study was limited by its conduction in a single medical center, its short evaluation of time post-CPOE (which might have largely been an adjustment period to the new system), and potential lack of generalizability to the rest of the hospital setting as all patients were transferred from outside hospitals. However, these findings highlighted how promising technologic advances could pose serious underlying consequences and that decreases in ADEs are not an indication of improved clinical outcomes. This study argued that technologic advances require careful, thorough evaluation in order to ensure that unexpected consequences do not negatively influence patient care. Current CPOE implementation involves active incorporation of the findings from this study to ensure effective prevention of potential complications.

Click to read the study in Pediatrics

In-Depth [retrospective analysis]: From October 1, 2001 to March 31, 2003, 1942 patients (55% male, median age = 9 months) were recruited upon arrival to a tertiary care center via interfacility transport. Overall, 1394 patients were admitted before CPOE implementation and 548 after. The clinical condition for admissions, patient demographics, clinical characteristics, and mortality for each patient were recorded. Between group differences were calculated using Mann-Whitney rank sum and X2 or Fisher’s tests. Odds ratios were calculated as well. Patients were transferred for the following conditions: airway- (42.6%), infectious disease- (34.9%), and central nervous system- (19.4%) related. A total of 75 children died during the study. Mortality increased significantly following CPOE implementation (2.80% before v. 6.57% after, P < 0.001). Odds of mortality were increased significantly if a patient experienced shock (OR = 6.24, 95% CI: 2.94-13.26), was treated following CPOE introduction (OR = 3.71, 95% CI: 2.13-6.46), or severe coma (OR = 3.43; 95%: 1.88-6.25). Additional adjustment for covariation resulted in maintained significance between CPOE and mortality (OR = 3.28, 95% CI: 1.94 – 5.55).

Researchers reported differences in clinical care following CPOE initiation. As the new system did not allow for orders to be entered prior to patient arrival, physicians spent several minutes per order entering requests into the system as opposed to the few seconds it would have taken to hand write the order. In addition, nurses were no longer at the bedside readily administering medications as CPOE implementation required all medications to be located within the pharmacy.

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