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REV: FEBRUARY 20, 2003

ANDR E W P. MCAFEE S A R A H M. MA CG R E G O R MICH A E L BE NA R I

Mount Auburn Hospital: Physician Order Entry
Introduction
In September of 2002, Robert Todd, the head of information systems (IS) for Mount Auburn Hospital in Cambridge, Massachusetts, reviewed progress toward the launch of the hospital’s new computerized physician order entry (POE) system. The committee overseeing the project consisted of an across-the-board selection of hospital representation, including physicians, pharmacy staff, nurses, administrators, and IS operations staff. The POE system was scheduled to ‚go live‛ on a pilot basis in the middle of October in the hospital’s labor and delivery unit. It had not been difficult to mount support for the project. POE systems had been demonstrated to reduce error rates, and medical errors were widely recognized as a large and serious problem in health care. A landmark study published in 19911 estimated that 1.3 million injuries occurred annually in U.S. hospitals, 69% of which were at last partially due to errors in patient management. The study found that 13% of injuries resulted in patient death, ‚a rate that if extrapolated to the United States as a whole suggested that approximately 180,000 deaths a year were, at least partly, the result of injuries received during the course of care.‛2 This study also found that adverse drug events (ADEs) accounted for nearly 20% of total injuries (making them the largest injury category) and that 45% of ADEs were the result of errors. A later study at two Boston hospitals found that 6.5% of admitted patients suffered an ADE, and that 28% of these were due to errors.3

1 L.L. Leape, T. A. Brennan, et al., ‚The nature of adverse events in hospitalized patients: results of the Harvard Medical

Practice Study II,‛ New England Journal of Medicine 324 (1991):