Clinical application of a computerized system for physician order entry with clinical decision support to prevent adverse drug events in long-term care.

simple prescribing decision can initiate unforeseen outcomes. The case described in Box 1 exemplifies how a cascade of unintended events can end in the development of a serious adverse drug event and in the elimination from a patient's medication regimen of a therapy that could have been beneficial if used safely. Evidence obtained in the acute care hospital sector 1 suggests that drug safety can be improved by means of computerized physician order entry (CPOE) with clinical decision support (CDS). Such improvements might be particularly important in long-term care. CPOE-CDS is an application that physicians use to enter patient prescriptions directly into a computer and receive immediate feedback about clinically important information that may improve their prescribing decision. 2,3 Specifically, an automated interface links the newly ordered drug therapy to clinical, drug and laboratory information in a way that guides prescription decisions in the direction of increased safety and ultimately reduces the medication errors that lead to adverse events. 4 For example, if a physician enters an order for an an-tidepressant drug for a patient already taking multiple psychoactive medications, the CDS system would display a warning about the potential for oversedation, confusion, delirium and falls. It would then advise the physician to evaluate the need for each psychoactive medication, indicate those already prescribed and suggest prescribing the lowest feasible dose of the new drug. CPOE-CDS is being used with success in acute care facilities. Use of CPOE was recommended in a 1999 Institute of Medicine report on reducing medical error, and one study 4 found that CPOE reduced serious medication errors by 55%. In 2000, the State of California passed a bill (California Senate Bill 1875) mandating that urban hospitals implement technological programs to reduce error (e.g., CPOE) by 2005. Implementation of such applications has been recommended as well by such US organizations as the Leapfrog Group (www.leapfroggroup.org) and the National Quality Forum (www.qualityforum.org). New strategies are needed to improve prescribing practices in extended care. On average, residents of long-term care facilities are prescribed more than 6 concurrent drug therapies. Such a high frequency of drug combinations among people of advanced age and who are often in frail condition markedly increases their potential for adverse events. When Gurwitz and colleagues 5 evaluated adverse drug events in 18 such facilities in the United States, monitoring nearly 3000 people for a total of 28 839 resident-months, they documented 546 adverse events. …