ABSTRACT
Use of computerized physician order entry (CPOE) systems for the placement of medication orders is part of the hospital-based and the eligible provider components of the US government's meaningful use incentives. [1] While CPOE has been shown to decrease medication errors [2-4] and in some studies mortality, [5] use of CPOE can also have unintended negative consequences, creating opportunities for or increasing the likelihood of certain types of medication errors. [6-9]
One potential problem with an electronic medical record (EMR) is the risk that a physician will accidentally enter orders in the wrong patient's chart. [8-10] In spite of all their disadvantages, paper charts afforded prescribers multiple visual cues that served to orient them to whether or not they were ordering for the correct patient, including the thickness of the chart, the handwriting, and the patient's problem list. [10] Most of these cues are either missing entirely or are less salient in the electronic environment, increasing the opportunity for wrong-chart errors. Use of patient lists may cause ‘pick-list’ or other user-interface driven errors, [7 ,11] and wrong patient selection may be facilitated by system features that allow clinicians to fi nd charts rapidly, such as the ability to select from a list of recently opened charts, or to have multiple patient charts open simultaneously.
