Skip to main content

Using Implementation Safety Indicators for CPOE Implementation

Buy Article:

$12.00 plus tax (Refund Policy)


Background: A computerized provider order entry (CPOE) system can decrease errors and improve quality but also may increase errors and harm. Yet, the current state of the literature on CPOE is particularly impoverished regarding implementation strategies and process measures.

Veterans Health Administration (VHA) CPOE Implementation: The VHA Computerized Patient Record System (CPRS), developed and implemented by the Department of Veterans Affairs (VA) at a national level, was designed to support physician order entry and electronic note entry. Implementation of CPRS was mandated for all clinical sites in the VA in a series of waves from 1997 through 2002. The study site, Salt Lake City Health Care System, is a 110-bed tertiary care university-affiliated facility. Local implementation was conducted in a staggered approach across clinical sites for a total implementation time of 24 months. Information theory is proposed as a basis for process assessment. Early in the process, the implementation team realized the need to create indicators to help monitor the process of change.

Results: The percent of orders entered by providers rose to 64% and leveled off. The percent of orders signed within four hours leveled off at 83%. The presence of inappropriate text orders (one-time review presented) was measured, and the percent of orders verified by nursing within two hours leveled off at 42%.

Discussion: Setting up an implementation monitoring process should start when the implementation process begins. Specific recommendations are as follows: (1) Start with the basic process measures, (2) set up reporting structures, and (3) start early with vendor negotiations. In conclusion, information theory provides an effective and efficient framework on which to base indicator development.

Document Type: Research Article

Publication date: 2009-01-01

More about this publication?
  • The Joint Commission Journal on Quality and Patient Safety will be published by Elsevier beginning in 2017! For readers who receive access to the journal through their institutions, the journal can now be found on ScienceDirect ( For librarians looking to subscribe to the journal for their institutions please contact your Elsevier Account Manager or visit for more information. All other readers, please visit to subscribe to the journal or to claim your access for an existing subscription.
  • Editorial Board
  • Information for Authors
  • Subscribe to this Title
  • Information for Advertisers
  • Reprints and Permissions
  • Index
  • Ingenta Connect is not responsible for the content or availability of external websites
  • Access Key
  • Free ContentFree content
  • Partial Free ContentPartial Free content
  • New ContentNew content
  • Open Access ContentOpen access content
  • Partial Open Access ContentPartial Open access content
  • Subscribed ContentSubscribed content
  • Partial Subscribed ContentPartial Subscribed content
  • Free Trial ContentFree trial content
Cookie Policy
Cookie Policy
Ingenta Connect website makes use of cookies so as to keep track of data that you have filled in. I am Happy with this Find out more