Interventions to reduce the incidence of medical error and its financial burden in health care systems: A systematic review of systematic reviews

Experts consider health information technology key to improving efficiency and quality of health care. To systematically review evidence on the effect of health information technology on quality, efficiency, and costs of health care. The authors systematically searched the English-language literature indexed in MEDLINE (1995 to January 2004), the Cochrane Central Register of Controlled Trials, the Cochrane Database of Abstracts of Reviews of Effects, and the Periodical Abstracts Database. We also added studies identified by experts up to April 2005. Descriptive and comparative studies and systematic reviews of health information technology. Two reviewers independently extracted information on system capabilities, design, effects on quality, system acquisition, implementation context, and costs. 257 studies met the inclusion criteria. Most studies addressed decision support systems or electronic health records. Approximately 25% of the studies were from 4 academic institutions that implemented internally developed systems; only 9 studies evaluated multifunctional, commercially developed systems. Three major benefits on quality were demonstrated: increased adherence to guideline-based care, enhanced surveillance and monitoring, and decreased medication errors. The primary domain of improvement was preventive health. The major efficiency benefit shown was decreased utilization of care. Data on another efficiency measure, time utilization, were mixed. Empirical cost data were limited. Available quantitative research was limited and was done by a small number of institutions. Systems were heterogeneous and sometimes incompletely described. Available financial and contextual data were limited. Four benchmark institutions have demonstrated the efficacy of health information technologies in improving quality and efficiency. Whether and how other institutions can achieve similar benefits, and at what costs, are unclear. Show more

Iatrogenic injuries related to medications are common, costly, and clinically significant. Computerized physician order entry (CPOE) and clinical decision support systems (CDSSs) may reduce medication error rates. We identified trials that evaluated the effects of CPOE and CDSSs on medication safety by electronically searching MEDLINE and the Cochrane Library and by manually searching the bibliographies of retrieved articles. Studies were included for systematic review if the design was a randomized controlled trial, a nonrandomized controlled trial, or an observational study with controls and if the measured outcomes were clinical (eg, adverse drug events) or surrogate (eg, medication errors) markers. Two reviewers extracted all the data. Discussion resolved any disagreements. Five trials assessing CPOE and 7 assessing isolated CDSSs met the criteria. Of the CPOE studies, 2 demonstrated a marked decrease in the serious medication error rate, 1 an improvement in corollary orders, 1 an improvement in 5 prescribing behaviors, and 1 an improvement in nephrotoxic drug dose and frequency. Of the 7 studies evaluating isolated CDSSs, 3 demonstrated statistically significant improvements in antibiotic-associated medication errors or adverse drug events and 1 an improvement in theophylline-associated medication errors. The remaining 3 studies had nonsignificant results. Use of CPOE and isolated CDSSs can substantially reduce medication error rates, but most studies have not been powered to detect differences in adverse drug events and have evaluated a small number of "homegrown" systems. Research is needed to evaluate commercial systems, to compare the various applications, to identify key components of applications, and to identify factors related to successful implementation of these systems. Show more

The objective of this systematic review is to analyse the relative risk reduction on medication error and adverse drug events (ADE) by computerized physician order entry systems (CPOE). We included controlled field studies and pretest-posttest studies, evaluating all types of CPOE systems, drugs and clinical settings. We present the results in evidence tables, calculate the risk ratio with 95% confidence interval and perform subgroup analyses for categorical factors, such as the level of care, patient group, type of drug, type of system, functionality of the system, comparison group type, study design, and the method for detecting errors. Of the 25 studies that analysed the effects on the medication error rate, 23 showed a significant relative risk reduction of 13% to 99%. Six of the nine studies that analysed the effects on potential ADEs showed a significant relative risk reduction of 35% to 98%. Four of the seven studies that analysed the effect on ADEs showed a significant relative risk reduction of 30% to 84%. Reporting quality and study quality was often insufficient to exclude major sources of bias. Studies on home-grown systems, studies comparing electronic prescribing to handwriting prescribing, and studies using manual chart review to detect errors seem to show a higher relative risk reduction than other studies. Concluding, it seems that electronic prescribing can reduce the risk for medication errors and ADE. However, studies differ substantially in their setting, design, quality, and results. To further improve the evidence-base of health informatics, more randomized controlled trials (RCTs) are needed, especially to cover a wider range of clinical and geographic settings. In addition, reporting quality of health informatics evaluation studies has to be substantially improved. Show more