“Data is variously described as the oxygen of the digital economy or the new raw material of the 21st century.“-Nigel Shadbolt
There are more than a few issues with today’s medication order entry systems. However, in this post I want to focus on only two.
First, alert fatigue. As a pharmacist that has entered his fair share of orders I can tell you that alert fatigue is real. Order entry systems, including CPOE, are designed to indiscriminately alert users of every possible problem associated with the patient’s profile and the order being entered. When entering orders for a patient with complex medical conditions, this can become a bit frustrating because a majority of these alerts are of little to no value. After a while you begin to blow through alerts because so many are simply a waste of your time. Unfortunately, when this happens you will occasionally miss something important. It happens.
Second, the “perfect medication error”.(1) This occurs when a physician inadvertently utilizes CPOE to order the wrong medication for a patient – or the right drug for the wrong patient – but the order meets all the necessary checks and balances to end up on the medication profile, i.e. no allergies, meets all appropriate dosing parameters, there are no drug-drug interactions, labs are fine, and so on. This is an issue that appeared on my radar while performing an FMEA for a CPOE implementation when I was still working as an IT pharmacist.