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Cited by 1,149Electronic Health Records SystemsPatient Safety and Medication ErrorsHospital Admissions and Outcomes

Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry System

Han, Yong Y., Carcillo, Joseph A., Venkataraman, Shekhar T., Clark, Robert S.B., Watson, R. Scott, Nguyen, Trung C., Bayir, Hülya, Orr, Richard A.·2005·Pediatrics
DOI 10.1542/peds.2005-1287
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Abstract

Objective. In response to the landmark 1999 report by the Institute of Medicine and safety initiatives promoted by the Leapfrog Group, our institution implemented a commercially sold computerized physician order entry (CPOE) system in an effort to reduce medical errors and mortality. We sought to test the hypothesis that CPOE implementation results in reduced mortality among children who are transported for specialized care. Methods. Demographic, clinical, and mortality data were collected of all children who were admitted via interfacility transport to our regional, academic, tertiary-care level children’s hospital during an 18-month period. A commercially sold CPOE program that operated within the framework of a general, medical-surgical clinical application platform was rapidly implemented hospital-wide over 6 days during this period. Retrospective analyses of pre-CPOE and post-CPOE implementation time periods (13 months before and 5 months after CPOE implementation) were subsequently performed. Results. Among 1942 children who were referred and admitted for specialized care during the study period, 75 died, accounting for an overall mortality rate of 3.86%. Univariate analysis revealed that mortality rate significantly increased from 2.80% (39 of 1394) before CPOE implementation to 6.57% (36 of 548) after CPOE implementation. Multivariate analysis revealed that CPOE remained independently associated with increased odds of mortality (odds ratio: 3.28; 95% confidence interval: 1.94–5.55) after adjustment for other mortality covariables. Conclusions. We have observed an unexpected increase in mortality coincident with CPOE implementation. 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.

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Crossref · 10.1542/peds.2005-1287

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  • Published typologies have not covered how the level of clinical-decision-support automation affects safety flaws and their chance of causing an incident.

    “In addition, the published typologies have not addressed such critical issues as the effect of the level of clinical-decision-support automation on safety flaws and their likelihood of contributing to a safety incident.14,47”

    From EHR Safety: The Way Forward to Safe and Effective Systems (2008) · cites this paper as [14]

  • Conflicting recent reports question how much CPOE truly improves care, noting that these systems have created new error types, harmed patient outcomes, and raised costs for adopting institutions.

    “Recent, conflicting reports about the role of CPOE in the reduction of medication errors and associated costs have cast some doubt on the actual scale of improvements to be gained as CPOE systems have generated new kinds of medical errors, negatively affected patient outcomes, and resulted in higher overall medical costs for those institutions implementing them.9,[11][12][13]”

    From Computerized Provider Order Entry Adoption: Implications for Clinical Workflow (2009) · cites this paper as [12]

  • eHealth may compromise patient safety in a number of ways.

    “eHealth may compromise patient safety in a number of ways.”

    From Evaluating eHealth Interventions: The Need for Continuous Systemic Evaluation (2009) · cites this paper as [13]

  • An unexpected increase in mortality was observed after the implementation of a commercially sold computerised physician order entry system; this increase may have been due to "system integration failure" and/or "human-machine interface flaws".

    “An unexpected increase in mortality was observed after the implementation of a commercially sold computerised physician order entry system; this increase may have been due to “system integration failure” and/or “human-machine interface flaws” [13].”

    From Evaluating eHealth Interventions: The Need for Continuous Systemic Evaluation (2009) · cites this paper as [13]

  • Relatively little time, thought, or resources have been devoted to assessing the potential risks associated with eHealth interventions.

    “it is of concern that, in this rush, relatively little time, thought, or resources have been devoted to assessing the potential risks associated with eHealth interventions [11]–[13],[33]–[36].”

    From Evaluating eHealth Interventions: The Need for Continuous Systemic Evaluation (2009) · cites this paper as [13]

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Authors
Han, Y. Y., Carcillo, J. A., Venkataraman, S. T., Clark, R. S. B., Watson, R. S., Nguyen, T. C., Bayir, H., & Orr, R. A.
Affiliations
  • Children's Hospital of Pittsburgh (US)
  • University of Pittsburgh (US)
  • Departments of Critical Care Medicine
ORCID
Venue
Pediatrics
Publisher
American Academy of Pediatrics (AAP)
Published
2005-12-01
Volume
116
Issue
6
Pages
1506-1512
ISSN
  • 0031-4005 (ISSN-L)
  • 1098-4275
DOI
10.1542/peds.2005-1287
OpenAlex
W2162040788
Cited by
1,149
References
26
Citations by year
2026: 9 · 2025: 7 · 2024: 11 · 2023: 20 · 2022: 20 · 2021: 25 · 2020: 24 · 2019: 47 · 2018: 22 · 2017: 30 · 2016: 61 · 2015: 86 · 2014: 75 · 2013: 89 · 2012: 94
FWCI
168.54
Type
journal article
Language
en
Open access
closed
Locations
  • PEDIATRICS (publishedVersion)
  • PubMed (publishedVersion)
Funders
  • U.S. Public Health Service (1-MCH-4240030-01-0)
  • Eunice Kennedy Shriver National Institute of Child Health and Human Development (T32HD040686)
Topics
  • Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
  • Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
  • Health Sciences › Medicine › Emergency Medicine › Hospital Admissions and Outcomes
Keywords
computerized physician order entry, CPOE implementation, child mortality, interfacility transport, medical errors, patient safety
MeSH terms
Child, Preschool, Female, Humans, Infant, Infant Mortality, Male, Outcome and Process Assessment, Health Care, Patient Transfer, Child Mortality, Medical Order Entry Systems

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