Checklists and CPOE: Silver Bullets for Medication Errors?

Checklists and CPOE: Silver Bullets for Medication Errors?

This is the second day of the week long exploration of care transitions and medication errors. Knowing the importance and vulnerability surrounding care transitions I will present findings from the literature regarding checklists and Computer Order Entry that will illuminate their “true” impact in reducing medication errors. For another look at how Hope Street Group conceives to Improve the quality and cost of transitions between acute and other types of care see our Using Open Innovation to Reinvent Primary Care report.


A check list is an “algorithmic listing of actions to be performed in a given clinical setting” with the goal of ensuring steps of a given task are not forgotten(Agency for Healthcare Research and Quality). Checklists are a favored intervention in patient safety since the majority of errors in health care are due to “slips” or failures due to distractions, fatigue or lack of attention (Agency for Healthcare Research and Quality). The use of checklists has the potential to convey and delineate the critical thinking, collaboration and goal setting needed for a successful transition to the next environment (Halasyamani, et al., 2006). The Society of Hospital Medicine leveraged this potential by creating a basic but comprehensive checklist of the processes and elements considered necessary for optimal patient handoff at hospital discharge (Halasyamani, et al., 2006). One of the most important aspects identified by the Society is the need to treat discharges as important and time intensive as admissions, since in essence, a discharge from on place is an “admission” to another.

In theory, checklists should be easy to reproduce and bring to scale as a valid intervention. However, the literature suggests that checklists may not be successful where the “gold standard” safety practices have yet to be determined, when the preparatory work of creating a safety culture has not taken place and when relevant co-interventions are not used (Agency for Healthcare Research and Quality). Further, checklists are not proven to impact errors that primarily involve attentional behavior or adaptive situations (Agency for Healthcare Research and Quality). Checklists need to be created and implemented with an understanding of local needs, organizational buy-in and evidence for targeted problem in order to lower barriers for use (Bosk, Dixon-Woods, Goeschel, & Pronovost, 2009). For example, checklists do not perform well when used to track baggage for airlines(Bosk, Dixon-Woods, Goeschel, & Pronovost, 2009). Bosk et al, state that this is a reasonable comparison to patient transitions since they both require: a high degree of coordination (often done poorly), ability to deal with schedule changes, time-pressured decision making and heterogeneous populations (Bosk, Dixon-Woods, Goeschel, & Pronovost, 2009). According to these authors, this is what has led the U.S. Veterans Affairs to classify checklists as weak interventions based on the low probability that they will reduce risks (Bosk, Dixon-Woods, Goeschel, & Pronovost, 2009).

Computerized Order Entry and Clinical Decision Support Systems

Computerized Provider Order Entry (CPOE) generally refers to a system in which clinicians directly enter medication orders into a computer system (Agency for Healthcare Research and Quality). It has been reported that 90% of inpatient medication errors occurred at either the ordering or transcribing stage (Bates, et al., 1995). These systems are more common in the inpatient setting than in the outpatient setting (Agency for Healthcare Research and Quality). Often, CPOE is paired with clinical decision support systems (CDSS), which can help prevent errors of commission and omission (Agency for Healthcare Research and Quality).

There are drawbacks to CPOE despite the fact that it directly addresses issues such as handwriting; drug interactions; similar drug names; system communication and adverse drug event reporting.(Agency for Healthcare Research and Quality). In fact, CDSS may be the key intervention in reducing errors in conjunction with CPOE since it has been reported that together (CPOE and CDSS), they reduced serious medication errors by 81% (National Priorities Partnership, 2010). However, the immediate implications of these findings are unclear. Although nursing homes are leading the way in terms of electronic medical record use (43%) it is unclear what percentage of those use CPOE (Leading Age, 2008). Additionally, the Agency for Healthcare Research and Quality (AHRQ) reports that only 17% of U.S. hospitals have implemented a CPOE system in 2009 (Agency for Healthcare Research and Quality). AHRQ also indicates that problems with CPOE include cost, time, onsite customization, resistance and interoperability. CPOE and CDSS appear to not be able to make a large impact based on the low and inconsistent penetration of these technologies.

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Agency for Healthcare Research and Quality. (2011 February). Nursing Home Survey on Patient Safety Culture. Retrieved 2011 10-August from Agency for Healthcare Research and Quality:

Agency for Healthcare Research and Quality. (n.d.). PSNET, Patient Safety Primer, Checklists. Retrieved 2011 10-August from Agency for Healthcare Research and Quality:[rimerID=14

Agency for Healthcare Research and Quality. (n.d.). PSNet, Patient Stafety Primer, Computerized Order Entry. Retrieved 2011 10-August from Agency for Healthcare Research and Quality:

Bosk, C., Dixon-Woods, M., Goeschel, C., & Pronovost, P. (2009). Reality Check for Checklists. The Lancet , 374 (9688), 444-445.

Halasyamani, L., Kripalani, S., Coleman, E., Schnipper, J., vanWalraven, C., Nagamine, J., et al. (2006). Transition of Care for Hospitalized Elderly Patients: Development of a Discharge Checklist for Hospitalists. Journal of Hospital Medicine , 1 (6), 354-360.

Leading Age. (2008 7-November). Press Release: Research Shows Nursing Homes Lead the Way in Electronic Health Record Use. Retrieved 2011 10-August from Leading Age:

National Priorities Partnership. (2011 10 August). National Qulaity Forurm, Overuse. Retrieved 2011 10-August from National Quality Forum:

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