Computerized provider order entry and patient safety : experiences from an Iranian teaching hospital

Background: Medication dosing errors may have grave consequences for neonatal patients. Computerized Physician Order Entry (CPOE) with dosing decision support functionalities has been effective in reducing these errors. However, the adoption rate is low. Physicians' resistance has been identified as a significant barrier. To reduce this resistance, the system should be designed in close collaboration with the users and reflect their needs. Some hospitals have used nurses as champions to reduce physicians' resistance. However, implementation of CPOE in middle- and low-income countries is more challenging because of several factors, including restrictions in budgets and human resources. Therefore, a careful design based on the users' requirements and contextual factors may increase the success rate in these contexts.

Objectives: To design and implement CPOE with dosing decision support functionalities in an Iranian teaching hospital and evaluate its effect on patient safety. Then tailor the system based on users' perception and compare the two implemented systems in terms of users' satisfaction and effect on patient safety.

Methods: Semi-structured interviews were used to gather prescribers' opinions on CPOE. On-looker observations were used to model the traditional prescription system. As an indicator of patient safety, medication dosing errors were evaluated in a neonatal ward in three periods: Traditional prescription system, physician order entry (POE) without decision support system (DSS), and POE with DSS. Explanations were then added and alerts appeared in every erroneous order, and the effect on dosing errors was compared with the previous period. Afterwards, the order entry was left to the nurses (NOE) but physicians verified the orders and received the warnings. Users' perceptions about POE and NOE were gathered using semi-structured interviews. POE and NOE with DSS were also compared for their effect on medication dosing errors.

Results: The traditional prescription system in Iran is hierarchical and physicians do not interact with the computer. However, in our study, physicians agreed to perform the order entry to be able to receive the warnings themselves. Prescribers prioritized dosing errors above other types of errors. Therefore, neonatal ward was selected as the relevant implementation unit. The rate of non-intercepted medication dosing errors was 53% in the traditional prescription system, which was not significantly different after the implementation of POE without DSS. However, after adding DSS to the POE, a significant reduction to 34% was observed (P<.001). Adding explanations to alerts and showing them in each erroneous order could further reduce the errors to 14% (P<.001). Implementation of NOE resulted in more satisfaction among nurses and physicians. They believed that in Iran, NOE was more transferable to the other hospitals than POE. Nonintercepted medication dosing errors were reduced from 14% in the last period of POE to 9% in NOE (P<.001).

Conclusions: On Iranian neonatal wards, POE without DSS has no apparent advantage over the traditional prescription system. However, together with DSS, POE can significantly reduce dosing errors. Despite the significance, in the hierarchical and physician-centred context of Iran, NOE seems to be a more viable prospect. This order entry method can increase care providers' satisfaction, and together with a dosing DSS it is as effective as or even more effective than POE in reducing dosing errors.

List of scientific papers

I. Kazemi A, Ellenius J, Tofighi S, Salehi A, Eghbalian F, Fors UG (2009). CPOE in Iran--a viable prospect? Physicians opinions on using CPOE in an Iranian teaching hospital. Int J Med Inform. 78(3): 199-207.
https://pubmed.ncbi.nlm.nih.gov/18760960

II. Kazemi A, Ellenius J, Pourasghar F, Tofighi S, Salehi A, Amanati A, Fors UG (2009). The effect of computerized physician order entry and decision support system on medication errors in the neonatal ward: Experiences from an Iranian teaching hospital. J Med Syst. 35, 25–37. Epub 2009 Jul 17.
https://pubmed.ncbi.nlm.nih.gov/20703588

III. Kazemi A, Fors UG, Tofighi S, Pezeshki N, Ellenius J (2009). Care providers perceptions of two strategies for implementing a computerized provider order entry system in an Iranian neonatal ward. [Submitted]

IV. Kazemi A, Fors UG, Tofighi S, Tessma MK, Ellenius (2009). Entry or Nurse Order Entry? Comparison of two implementation strategies for a computerized order entry system aiming at reducing dosing medication errors in a neonatal ward in Iran. [Submitted]