Journal of Medical Systems

, Volume 35, Issue 1, pp 25–37 | Cite as

The Effect of Computerized Physician Order Entry and Decision Support System on Medication Errors in the Neonatal Ward: Experiences from an Iranian Teaching Hospital

  • Alireza Kazemi
  • Johan Ellenius
  • Faramarz Pourasghar
  • Shahram Tofighi
  • Aref Salehi
  • Ali Amanati
  • Uno GH Fors
Original Paper


Medication dosing errors are frequent in neonatal wards. In an Iranian neonatal ward, a 7.5 months study was designed in three periods to compare the effect of Computerized Physician Order Entry (CPOE) without and with decision support functionalities in reducing non-intercepted medication dosing errors in antibiotics and anticonvulsants. Before intervention (Period 1), error rate was 53%, which did not significantly change after the implementation of CPOE without decision support (Period 2). However, errors were significantly reduced to 34% after that the decision support was added to the CPOE (Period 3; P < 0.001). Dose errors were more often intercepted than frequency errors. Over-dose was the most frequent type of medication errors and curtailed-interval was the least. Transcription errors did not reduce after the CPOE implementation. Physicians ignored alerts when they could not understand why they appeared. A suggestion is to add explanations about these reasons to increase physicians’ compliance with the system’s recommendations.


Medical order entry systems Decision support systems, clinical Medication errors Infant, newborn Patient safety Iran 


  1. 1.
    Classen, D. C., Pestotnik, S. L., Evans, R. S., Lloyd, J. F., and Burke, J. P., Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality. JAMA. 227:301–306, 1997.CrossRefGoogle Scholar
  2. 2.
    Levine, S. R., Cohen, M. R., Blanchard, N. R., Frederico, F., Magelli, M., Lomax, C., et al., Guidelines for preventing medication errors in pediatrics. J. Pediatr. Pharmacol. Therapeut. 6:426–442, 2001.Google Scholar
  3. 3.
    Gray, J. E., and Goldmann, D. A., Medication errors in the neonatal intensive care unit: special patients, unique issues. Arch. Dis. Child. Fetal Neonatal Ed. 89:F472–F473, 2004.CrossRefGoogle Scholar
  4. 4.
    Kunac, D. L., and Reith, D. M., Identification of priorities for medication safety in neonatal intensive care. Drug Saf. 28:251–261, 2005.CrossRefGoogle Scholar
  5. 5.
    Kaushal, R., Bates, D. W., Landrigan, C., McKenna, K. J., Clapp, M. D., Federico, F., et al., Medication errors and adverse drug events in pediatric inpatients. JAMA. 285:2114–2120, 2001.CrossRefGoogle Scholar
  6. 6.
    Ross, L. M., Wallace, J., Paton, J. Y., and Stephenson, T., Medication errors in a paediatric teaching hospital in the UK: five years operational experience. Arch. Dis. Child. 83:492–497, 2000.CrossRefGoogle Scholar
  7. 7.
    Lowry, J. A., Vandover, J. C., DeGreeff, J., and Scalzo, A. J., Unusual presentation of iatrogenic phenytoin toxicity in a newborn. J. Med. Toxicol. 1:26–29, 2005.CrossRefGoogle Scholar
  8. 8.
    Bates, D. W., Leape, L. L., Cullen, D. J., Laird, N., Petersen, L. A., Teich, J. M., et al., Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 280:1311–1316, 1998.CrossRefGoogle Scholar
  9. 9.
    Bates, D. W., Teich, J. M., Lee, J., Seger, D. L., Kuperman, G. J., Ma’Luf, N., et al., The impact of computerized physician order entry on medication error prevention. JAMIA. 6:313–321, 1999.Google Scholar
  10. 10.
    Chedoe, I., Molendijk, H. A., Dittrich, S. T., Jansman, F. G., Harting, J. W., Brouwers, J. R., et al., Incidence and nature of medication errors in neonatal intensive care with strategies to improve safety: a review of the current literature. Drug Saf. 30:503–513, 2007.CrossRefGoogle Scholar
  11. 11.
    Eslami, S., Keizer, N. F., and Abu-Hanna, A., The impact of computerized physician medication order entry in hospitalized patients—a systematic review. Int. J. Med. Inform. 77:365–376, 2008.CrossRefGoogle Scholar
  12. 12.
    Ghaleb, M. A., Barber, N., Franklin, B. D., Yeung, V. W., Khaki, Z. F., and Wong, I. C., Systematic review of medication errors in pediatric patients. Ann. Pharmacother. 40:1766–1776, 2006.CrossRefGoogle Scholar
  13. 13.
    Berger, R. G., and Kichak, J. P., Computerized physician order entry: helpful or harmful? JAMIA. 11:100–103, 2004.Google Scholar
  14. 14.
    Koppel, R., Metlay, J. P., Cohen, A., Abaluck, B., Localio, A. R., Kimmel, S. E., et al., Role of computerized physician order entry systems in facilitating medication errors. JAMA. 293:1197–1203, 2005.CrossRefGoogle Scholar
  15. 15.
    McAlearney, A. S., Chisolm, D. J., Schweikhart, S., Medow, M. A., and Kelleher, K., The story behind the story: physician skepticism about relying on clinical information technologies to reduce medical errors. Int. J. Med. Inform. 76:836, 2007.CrossRefGoogle Scholar
  16. 16.
    Zhan, C., Hicks, R. W., Blanchette, C. M., Keyes, M. A., and Cousins, D. D., Potential benefits and problems with computerized prescriber order entry: analysis of a voluntary medication error-reporting database. Am. J. Health Syst. Pharm. 63:353–358, 2006.CrossRefGoogle Scholar
  17. 17.
    Han, Y. Y., Carcillo, J. A., Venkataraman, S. T., Clark, R. S. B., Watson, R. S., Nguyen, T. C., et al., Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics. 116:1506–1512, 2005.CrossRefGoogle Scholar
  18. 18.
    Ammenwerth, E., Talmon, J., Ash, J. S., D.W., B., Beuscart-Zéphir, M. C., Duhamel, A., et al., Impact of CPOE on mortality rates–contradictory findings, important messages. Methods Inf. Med. 45:586–593, 2006.Google Scholar
  19. 19.
    Gard, J. W., Starnes, H. M., Morrow, E. L., Sanchez, P. J., and Perlman, J. M., Reducing antimicrobial dosing errors in a neonatal intensive care unit. Am. J. Health Syst. Pharm. 52:1512–1513, 1995.Google Scholar
  20. 20.
    Cordero, L., Kuehn, L., Kumar, R. R., and Mekhjian, H. S., Impact of computerized physician order entry on clinical practice in a newborn intensive care unit. J. Perinatol. 24:88–93, 2004.CrossRefGoogle Scholar
  21. 21.
    Poon, E. G., Blumenthal, D., Jaggi, T., Honour, M. M., Bates, D. W., and Kaushal, R., Overcoming barriers to adopting and implementing computerized physician order entry systems in U.S. hospitals. Health Aff. (Millwood). 23:184–190, 2004.CrossRefGoogle Scholar
  22. 22.
    Kaushal, R., Jha, A. K., Franz, C., Glaser, J., Shetty, K. D., Jaggi, T., et al., Return on investment for a computerized physician order entry system. JAMIA. 13:261–266, 2006.Google Scholar
  23. 23.
    van der Sijs, H., Aarts, J., Vulto, A., and Berg, M., Overriding of drug safety alerts in computerized physician order entry. JAMIA. 13:138–147, 2006.Google Scholar
  24. 24.
    Aarts, J., and Koppel, R., Implementation of computerized physician order entry in seven countries. Health Aff. 28:404–414, 2009.CrossRefGoogle Scholar
  25. 25.
    Teufel, R. J. II, Swanson Kazley, A., and Basco, W. T. Jr., Early adopters of computerized physician order entry in hospitals that care for children: a picture of US health care shortly after the Institute of Medicine reports on quality. Clin. Pediatr. (Phila). 48:389–396, 2009.CrossRefGoogle Scholar
  26. 26.
    Kazemi, A., Ellenius, J., Tofighi, S., Salehi, A., Eghbalian, F., and Fors, U. G., CPOE in Iran—a viable prospect? Physicians’ opinions on using CPOE in an Iranian teaching hospital. Int. J. Med. Inform. 78:199–207, 2009.CrossRefGoogle Scholar
  27. 27.
    World Health Organization, World Health Statistics 2008. WHO, France, 2008.Google Scholar
  28. 28.
    World Health Organization, Country cooperation strategy for WHO and the Islamic Republic of Iran 2005–2009. Pulp Pictures, Cairo, 2006.Google Scholar
  29. 29.
    Gholami, K., and Shalviri, G., Factors associated with preventability, predictability, and severity of adverse drug reaction. Ann. Pharmacother. 33:236–240, 1999.CrossRefGoogle Scholar
  30. 30.
    Zargarzadeh, A. H., Emami, M. H., and Hosseini, F., Drug-related hospital admissions in a generic pharmaceutical system. Clin. Exp. Pharmacol. Physiol. 34:494–498, 2007.CrossRefGoogle Scholar
  31. 31.
    Stoll, B. J., Infections of the neonatal infant—suggested dosage schedules for antibiotics used in newborns. In: Behrman, R. E., Kleigman, R. M., and Jenson, H. B. (Eds.), Nelson Textbook of Pediatrics, 17th edition. Saunders, Philadelphia, p. 637, 2004.Google Scholar
  32. 32.
    Gal, P., and Reed, M. D., Laboratory medicine, drug therapy, and reference tables—medications. In: Behrman, R. E., Kleigman, R. M., and Jenson, H. B. (Eds.), Nelson Textbook of Pediatrics, 17th edition. Saunders, Philadelphia, pp. 2473–2474, 2004.Google Scholar
  33. 33.
    Omokaro, S. O., Nephrology—normal values of GFR. In: Robertson, J., and Shilkofski, N. (Eds.), The Harriet Lane Handbook: A Manual for Pediatric House Officers, 17th edition. The Harriet Lane Service, Children’s Medical and Surgical Center of, the Johns Hopkins Hospital, Philadelphia, p. 495, 2005.Google Scholar
  34. 34.
    Davis, I. D., and Avner, E. D., Glomerular disease. In: Behrman, R. E., Kleigman, R. M., and Jenson, H. B. (Eds.), Nelson Textbook of Pediatrics, 17th edition. Saunders, Pennsylvania, p. 1733, 2004.Google Scholar
  35. 35.
    GraphPad Software. Analyze a 2x2 contingency table. GraphPad QuickCalcs 2005 [cited 2008 5 June]. Available from:
  36. 36.
    Dean, A. G., Dean, J. A., Coulombier, D., Brendel, K. A., Smith, D. C., Burton, A. H., et al., Chi square for trend. In: Epi Info™ (Ed.), Statcalc, 6th edition. Centers for Disease Control and Prevention, Atlanta, Georgia, 1996.Google Scholar
  37. 37.
    Conroy, S., Sweis, D., Planner, C., Yeung, V., Collier, J., Haines, L., et al., Interventions to reduce dosing errors in children: a systematic review of the literature. Drug Saf. 30:1111–1125, 2007.CrossRefGoogle Scholar
  38. 38.
    Garrelts, J. C., Koehn, L., Snyder, V., Snyder, R., and Rich, D. S., Automated medication distribution systems and compliance with Joint Commission standards. Am. J. Health Syst. Pharm. 58:2267–2272, 2001.Google Scholar
  39. 39.
    Simborg, D. W., and Derewicz, H. J., A highly automated hospital medication system. Five years’ experience and evaluation. Ann. Intern. Med. 83:342–346, 1975.Google Scholar
  40. 40.
    Leape, L. L., Cullen, D. J., Clapp, M. D., Burdick, E., Demonaco, H. J., Erickson, J. I., et al., Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 282:267–270, 1999.CrossRefGoogle Scholar
  41. 41.
    Simpson, J. H., Lynch, R., Grant, J., and Alroomi, L., Reducing medication errors in the neonatal intensive care unit. Arch. Dis. Child Fetal Neonatal. Ed. 89:F480–482, 2004.CrossRefGoogle Scholar
  42. 42.
    Daschner, M., Drug dosage in children with reduced renal function. Pediatr. Nephrol. 20:1675–1686, 2005.CrossRefGoogle Scholar
  43. 43.
    Patrick, C. H., Therapeutic drug monitoring in neonates. Neonatal Netw. 14:21–26, 1995.Google Scholar
  44. 44.
    Glover, M. L., and Sussmane, J. B., Assessing pediatrics residents’ mathematical skills for prescribing medication: a need for improved training. Acad. Med. 77:1007–1010, 2002.CrossRefGoogle Scholar
  45. 45.
    Rowe, C., Koren, T., and Koren, G., Errors by paediatric residents in calculating drug doses. Arch. Dis. Child. 79:56–58, 1998.CrossRefGoogle Scholar
  46. 46.
    Flynn, E. A., Barker, K. N., Pepper, G. A., Bates, D. W., and Mikeal, R. L., Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am. J. Health Syst. Pharm. 59:436–446, 2002.Google Scholar
  47. 47.
    Hsueh, Y., The Hawthorne experiments and the introduction of Jean Piaget in American industrial psychology, 1929–1932. Hist. Psychol. 5:163–189, 2002.CrossRefGoogle Scholar
  48. 48.
    Shulman, R., Singer, M., Goldstone, J., and Bellingan, G., Medication errors: a prospective cohort study of hand-written and computerised physician order entry in the intensive care unit. Crit. Care. 9:516–521, 2005.CrossRefGoogle Scholar
  49. 49.
    Ash, J. S., Fournier, L., Stavri, P. Z., and Dykstra, R., Principles for a successful computerized physician order entry implementation. AMIA Annu. Symp. Proc. 2003:36–40, 2003.Google Scholar
  50. 50.
    Beuscart-Zephir, M. C., Pelayo, S., Anceaux, F., Meaux, J. J., Degroisse, M., and Degoulet, P., Impact of CPOE on doctor–nurse cooperation for the medication ordering and administration process. Int. J. Med. Inform. 74:629–641, 2005.CrossRefGoogle Scholar
  51. 51.
    Brisset, P. R., Gilman, C. S., Morgan, M. T., Shabot, M. M., and Hallman, E., Who are your CPOE users and how do you train them? Lessons learned at Cedars-Sinai health system. Medinfo. 2004:1536, 2004.Google Scholar
  52. 52.
    Ghosh, T., Norton, M., and Skiba, D., Communication, coordination and knowledge sharing in the implementation of CPOE: impact on nursing practice. AMIA Annu. Symp. Proc. 2006:928, 2006.Google Scholar
  53. 53.
    Ross, C., and Banchy, P., The key to CPOE. Health Manag. Technol. 28:22–24, 2007.Google Scholar
  54. 54.
    Mekhjian, H. S., Kumar, R. R., Kuehn, L., Bentley, T. D., Teater, P., Thomas, A., et al., Immediate benefits realized following implementation of physician order entry at an academic medical center. JAMIA. 9:529–539, 2002.Google Scholar
  55. 55.
    Pourasghar, F., Malekafzali, H., Kazemi, A., Ellenius, J., and Fors, U. G., What they fill in today, may not be useful tomorrow: Lessens learned from studying of medical records at the Women hospital in Tabriz, Iran’ Published in BMC Public Health. BMC Public Health. 8:139, 2008.CrossRefGoogle Scholar
  56. 56.
    Myers, T. F., Venable, H. H., and Hansen, J. A., Computer-enhanced neonatology practice evolution in an academic medical center. NICU Clinical Effectiveness Task Force. J. Perinatol. 18:S38–44, 1998.Google Scholar
  57. 57.
    van der Sijs, H., Aarts, J., van Gelder, T., Berg, M., and Vulto, A., Turning off frequently overridden drug alerts: limited opportunities for doing it safely. JAMIA. 15:439–448, 2008.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  • Alireza Kazemi
    • 1
    • 2
    • 3
  • Johan Ellenius
    • 1
  • Faramarz Pourasghar
    • 1
  • Shahram Tofighi
    • 4
  • Aref Salehi
    • 5
  • Ali Amanati
    • 6
  • Uno GH Fors
    • 1
  1. 1.Department of Learning, Informatics, Management and Ethics (LIME)StockholmSweden
  2. 2.Management Information Systems CentreHamadan University of Medical SciencesHamadanIran
  3. 3.National Public Health Management Centre (NPMC)TabrizIran
  4. 4.School of Health Services Management and InformaticsIran University of Medical SciencesTehranIran
  5. 5.Department of CardiologyGorgan University of Medical SciencesGorganIran
  6. 6.Department of PaediatricsHamadan University of Medical SciencesHamadanIran

Personalised recommendations