Case Study: In order to improve patient safety and efficiency, XYZ Hospital recently implemented a clinical provider
order entry (CPOE) system. One of the functions of the CPOE system is to notify physicians of any problems at the
time that an order is entered. Days after the CPOE system was implemented, Dr. Smith ordered medication X for a
patient named Mary Johnson. Immediately, the CPOE came back with a message stating that medication X was
contraindicated (not recommended) for patients on medication Y and that Mary was taking medication Y. Dr. Smith
realized that he had almost ordered a medication that could have significantly harmed Mary. He was able to delete
the order of medication X and order medication Z instead. Mary received her medication in a timely manner and was
discharged from the hospital in two days. 20 points.
Question 1: How is data quality related to this case? Before responding, read Chapter 2: Information Integrity and
Data Quality. In addition, read the Quality section in Chapter 8, Administrative Information Systems, to get a better
understanding of the CPOE. Address data from both chapters, including the CPOE, Patient Medication, and
physician’s responsibility in the CPOE.
Question 2: What impact does entering an incorrect medication have? Be sure to address poor data quality and
patient medication in your response.
Expert Solution Preview
This case study describes the implementation of a clinical provider order entry (CPOE) system in a hospital setting. It focuses on how a physician almost ordered a medication that could have harmed a patient, but was prevented from doing so by the CPOE system. Two questions related to data quality and patient safety are asked, and both must be answered independently and in detail.
Answer to Question 1:
Data quality is critical in this case as it determines the accuracy of the information that the CPOE system relies on to alert physicians of potential harm to patients. Data integrity issues such as incomplete or inaccurate patient information, incorrect dosages, or missing drug allergy data could lead to incorrect medication orders or the failure of the CPOE to trigger alerts for physicians. For example, if the medication Y that Mary was taking had not been properly documented in the system, the CPOE would not have issued a warning to Dr. Smith. Additionally, physician responsibility in the CPOE system plays a key role in the quality of data. Physicians must ensure that patient data is complete and correct to enable the CPOE system to function optimally. Therefore, data quality is directly linked to patient safety in the context of the CPOE system.
Answer to Question 2:
Entering an incorrect medication can have serious consequences for patient safety. In this case, had Dr. Smith not received the warning from the CPOE system, Mary would have received medication X, which was contraindicated due to her other medication. This could have led to adverse drug reactions, increased the risk of complications, and prolonged her stay in the hospital, which is not cost-effective for the hospital. Poor data quality, such as incomplete or missing drug allergy information, could also have contributed to such an error. Therefore, patient medication safety is critical, and it is imperative that data quality is maintained to prevent medication errors and ensure patient safety.