Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry

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The purpose of this study was to compare the number and type of medication errors reported before and after the implementation of computerized prescriber order entry (CPOE); the involvement of a pharmacy resident in the CPOE implementation process will be described.


CPOE implementation in the neurosurgical intensive care unit (ICU) began on September 14, 2004. The critical care pharmacy resident, pharmacy faculty preceptor on service, critical care pharmacy team, CPOE implementation team, and director of pharmacy were integral parts of this process. Protocols and order sets were developed before CPOE implementation to standardize frequent orders, expedite their entry, and potentially decrease errors. The number of medication errors reported each month from October 2002 through November 2004 was calculated and compared, the type and severity of medication errors between September and October 2003 and September and October 2004 were compared, and the personnel reporting medication errors were compared for time points before and after CPOE implementation.


The number of ordering errors on this service, most of which were presumed to have originated from physicians, demonstrated a fivefold increase over the same month the previous year. However, despite this increase in quantity, the majority of medication errors did not result in harm to the patient. The greatest number of medication errors was reported by the pharmacy resident on service, far exceeding the number of errors reported by pharmacists the previous year.


An increase in the number of medication errors reported was observed during the initial transition period after CPOE implementation. Pharmacy departments and pharmacy residents can have a significant effect on the ease and safety of CPOE implementation.

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