1. Fieleke, Kyle

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The news item "To Err Is Not Surprising" (News, June) cited a Journal of the American Medical Association study on computerized physician order entry (CPOE) systems, in which Koppel and colleagues concluded, "a leading CPOE system often facilitated medication error risks, with many reported to occur frequently." 1AJN readers should be aware that the study was based on only one hospital and an antiquated CPOE system. The study was much too narrow in scope to be applied broadly to all CPOE systems.


Sajjad Yacoob, MD, director of Medical Informatics at Childrens Hospital Los Angeles, published a response to the study on stating that it "can be compared to researching a 1970s model Ford Pinto and concluding that all cars are in danger of blowing up." 2 Yacoob points out that the 22 potential errors outlined in the study are process issues rather than software issues, and that each of them can be addressed by a modern CPOE system that is unified with the pharmacy's system. Childrens Hospital Los Angeles has in fact implemented this type of "closed loop" system, and has already realized benefits, including increased patient safety and regulatory compliance.


Kyle Fieleke


Evanston, IL




1. Koppel R, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA 2005;293(10):1197-203. [Context Link]


2. Yacoob S. Reader defends patient-safety benefits of CPOE. Modern Physician Stat 2005 Mar 17. [Context Link]