Impact of Emerging Technologies on Medication Errors and Adverse Drug Events

Authors and Disclosures

Eyal Oren, B.A., is Research Associate; Ellen R. Shaffer, Ph.D., is Assistant Clinical Professor; and B. Joseph Guglielmo, Pharm.D., is Professor and Vice Chair, Department of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco.

Sidebar: Appendix A - Excluded Articles Pertaining to Computerized Physician Order Entry

1. Ahmad A, Teater P, Bentley TD et al. Key attributes of a successful physician order entry system implementation in a multi-hospital environment. J Am Med Inform Assoc. 2002; 9:16-24.

2. Allen S, Johannes R, Brown C et al. Prescription-writing with a PC. Comput Methods Programs Biomed. 1986; 22:127-35.

3. Ash J, Gorman P, Hersh W. Physician order entry in U.S. hospitals. Proc AMIA Annu Fall Symp. 1998; 235-9.

4. Ash J, Gorman P, Hersh W et al. Perceptions of house officers who use physician order entry. Proc AMIA Annu Fall Symp. 1999; 471-5.

5. Ash J, Gorman P, Lavelle M et al. Investigating physician order entry in the field: lessons learned in a multi-center study. Medinfo. 2001; 10(pt. 2):1107-11.

6. Ash JS, Gorman PN, Lavelle M et al. Multiple perspectives on physician order entry. Proc AMIA Symp. 2000; 27-31.

7. Bates D, Kuperman G, Teich J. Computerized physician order entry and quality of care. Qual Manage Health Care. 1994; 2:18-27.

8. Bates D, Shu K, Narasimhan D et al. Comparing time spent writing orders on paper and physician computer order entry. Proc AMIA Annu Fall Symp. 2000; 965.

9. Bates DW, Cohen M, Leape LL et al. Reducing the frequency of errors in medicine using information technology. J Am Med Inform Assoc. 2001; 8:299-308.

10. Bates DW, O'Neil AC, Boyle D et al. Potential identifiability and preventability of adverse events using information systems. JAMA. 1994; 1:404-11.

11. Birkmeyer J, Birkmeyer C, Wennberg D et al. Leapfrog safety standards: potential benefits of universal adoption. Washington, DC: Leapfrog Group; 2000.

12. Bodenheimer T. The American health care system: the movement for improved quality in health care. N Engl J Med. 1999; 340:488-92.

13. Broverman C, Clyman J, Schlesinger J et al. Clinical decision support for physician order-entry: design challenges. Proc AMIA Annu Fall Symp. 1996; 572-6.

14. Brown C, Allen S, Songco D. A computerized prescription writing program for doctors. Methods Inf Med. 1985; 24:101-5.

15. Burke J, Pestotnik S. Antibiotic use and microbial resistance in intensive care units: impact of computer-assisted decision support. J Chemother. 1999; 11:530-5.

16. Canfield K. Priming intelligent split menus with text corpora for computerized patient record data-entry. Int J Biomed Comput. 1995; 39:263-73.

17. Chin H. Winning support for physician order entry. Health Data Manage. 1999; 7(5):54-6,60,62-3.

18. Chin H, Krall M. Implementation of a comprehensive computer-based patient record system in Kaiser Permanente's Northwest region. MD Comput. 1997; 14(1):41-5.

19. Chin H, Wallace P. Embedding guidelines into direct physician order entry: simple methods, powerful results. Proc AMIA Symp. 1999; 221-5.

20. Classen D, Pestotnik S, Evans R et al. Computerized surveillance of adverse drug events in hospital patients. JAMA. 1991; 266:2847-51.

21. Classen D, Pestotnik S, Evans R et al. Description of a computerized adverse drug event monitor using a hospital information system. Hosp Pharm. 1992; 27: 774,776-9,783.

22. Collen M. General requirements for a medical information system (MIS). Comput Biomed Res. 1970; 3:393-406.

23. Computerized provider order entry systems. Health Devices. 2001; 30:323-59.

24. Computerized provider order entry systems. Not a panacea for medical errors. Health Devices. 2001; 30:321-2.

25. Dambro M, Weiss B, McClure C et al. An unsuccessful experience with computerized medical records in an academic medical center. J Med Educ. 1988; 63:617-23.

26. Donald J. On line prescribing by computer. BMJ. 1986; 292:937-9.

27. Dorodny VS. Security and confidentiality of health information systems: implications for physicians. Physician Exec. 1998; 24(3):32-7.

28. East T, Morris A, Wallace C. A strategy for development of computerized critical care decision support systems. Int J Clin Monit Comput. 1991; 8:263-9.

29. Evans R, Classen D, Pestotnik S et al. Improving empiric antibiotic selection using computer decision support. Arch Intern Med. 1994; 154:878-84.

30. Evans R, Pestotnik S, Classen D et al. Preventing adverse drug events in hospitalized patients. Ann Pharmacother. 1994; 28:523-7.

31. Evans R, Pestotnik S, Classen D et al. Prevention of adverse drug events through computerized surveillance. Proc Annu Symp Comput Appl Med Care. 1992; 437-41.

32. Fabrey RH II. Physician computer order entry in a hospital setting. Physician Exec. 1996; 22(4):31-3.^a

33. Geissbuhler A, Miller RA. A new approach to the implementation of direct care-provider order entry. Proc AMIA Annu Fall Symp. 1996; 689-93.

34. Geissbuhler A, Miller RA. Clinical application of the UMLS in a computerized order entry and decision-support system. Proc AMIA Symp. 1998; 320-4.

35. Glaser J, Teich J, Kuperman G. Impact of information events on medical care. In: Proceedings of the Healthcare Information and Management Systems Society Annual Conference. Vol. 2. San Francisco: Jossey-Bass/Pfeiffer; 1996:1-9.

36. Goverman IL. Orienting health care information systems toward quality: how Group Health Cooperative of Puget Sound did it. Jt Comm J Qual Improv. 1994; 20(11):595-605.

37. Grams S, Grieco A, Williams R. Physician use of the TDS medical information system provides major benefits and savings to New York University Medical Center. New York: New York University; 1986.

38. Hawkins HH, Hankins RW, Johnson E. A computerized physician order entry system for the promotion of ordering compliance and appropriate test utilization. J Healthc Inf Manage. 1999; 13(3):63-72.

39. Johnston M, Langton K, Haynes R et al. Effects of computer-based clinical decision support systems on clinician performance and patient outcome: a critical appraisal of research. Ann Intern Med. 1994; 120:135-42.

40. Kaplan B. Reducing barriers to physician data entry for computer-based patient records. Top Health Inf Manage. 1994; 15(1):24-34.

41. Kawahara NE, Jordan FM. Influencing prescribing behavior by adapting computerized order-entry pathways. Am J Hosp Pharm. 1989; 46:1798-801.

42. Khorasani R. Computerized physician order entry and decision support: improving the quality of care. Radiographics. 2001; 21:1015-8.

43. Kuperman GJ, Teich JM, Gandhi TK et al. Patient safety and computerized medication ordering at Brigham and Women's Hospital. Jt Comm J Qual Improv. 2001; 27:509-21.

44. Larson R, Blake J. Achieving order entry by physicians in a computerized medical record. Hosp Pharm. 1988; 23:551-3.

45. Larsen R, Evans R, Burke J et al. Improved perioperative antibiotic use and reduced surgical wound infections through use of computer decision analysis. Infect Control Hosp Epidemiol. 1989; 10:316-20.

46. Lee F, Teich J, Spurr C et al. Implementation of physician order entry: user satisfaction and self-reported usage patterns. J Am Med Inform Assoc. 1996; 3:42-55.

47. Lee YL, Hsu CY, Hsieh D et al. Development and deployment of a Web-based physician order entry system. Int J Med Inf. 2001; 62(2-3):135-42.

48. Lepage E, Gardener R, Laub R et al. Improving blood transfusion practice: role of a computerized hospital information system. Transfusion. 1992; 32:253-9.

49. Levit F, Garside D. Computer-assisted prescription writing. Comput Biomed Res. 1977; 10:501-10.

50. Litzelman D, Dittus R, Miller M et al. Requiring physicians to respond to computerized reminders improves their compliance with preventive care protocols. J Gen Intern Med. 1993; 8:311-7.

51. Lobach D, Hammond W. Computerized decision support based on a clinical practice guideline improves compliance with care standards. Am J Med. 1997; 102:89-98.

52. Luxenberg SN, DuBois DD, Fraley CG et al. Electronic forms: benefits and drawbacks of a World Wide Web-based approach to data entry. Proc AMIA Annu Fall Symp. 1997; 804-8.

53. Marino R. CPOE systems not ready yet. Hosp Health Netw. 2001; 75(9):12,14.

54. Massaro T. Introducing physician order entry at a major academic medical center: I. Impact on organizational culture and behavior. Acad Med. 1993; 68(1):20-5.

55. Massaro T. Introducing physician order entry at a major academic medical center: II. Impact on medical education. Acad Med. 1993; 68(1):25-30.

56. Murff H, Kannry J. Physician satisfaction with two order entry systems. J Am Med Inform Assoc. 2001; 8:499-509.

57. Norris PR, Dawant BM, Geissbuhler A. Web-based data integration and annotation in the intensive care unit. Proc AMIA Annu Fall Symp. 1997; 794-8.

58. Ogura H, Sagara E, Yamamoto K et al. Analysis of the online order entry process in an integrated hospital information system. Comput Biol Med. 1985; 15:381-93.

59. Ogura H, Yamamoto K, Furutani H et al. On-line prescription order and prescription support in an integrated hospital information system. Med Inform (Lond). 1985; 10:287-99.

60. Overhage J, Tierney W, McDonald C et al. Computer-assisted order entry: impact on intern time use. Clin Res. 1991; 39:794. Abstract.

61. Overhage JM, Mamlin B, Warvel J et al. A tool for provider interaction during patient care: G-CARE. Proc Annu Symp Comput Appl Med Care. 1995; 178-82.

62. Paterno M, Teich J, Seger D et al. A practical method for presenting drug interactions to clinicians. Proc AMIA Annu Fall Symp. 1996; 20:872.

63. Payne TH. The transition to automated practitioner order entry in a teaching hospital: the VA Puget Sound experience. Proc AMIA Symp. 1999; 589-93.

64. Pestotnik S, Classen D, Evans R et al. Implementing antibiotic practice guidelines through computer-assisted decision support: clinical and financial outcomes. Ann Intern Med. 1996; 124:884-90.

65. Pestotnik SL, Classen DC, Evans RS et al. Prospective surveillance of imipenem/cilastatin use and associated seizures using a hospital information system. Ann Pharmacother. 1993; 27:497-501.

66. Physician order entry system cuts error rate, improves path compliance, tracks data. Health Care Cost Reeng Rep. 1997; 2(10):152-7

67. Pryor T, Gardner R, Clayton P et al. The HELP system. J Med Syst. 1983; 7:87-102.

68. Raschke R, Golihare B, Wunderlich T. A computer alert system to prevent injury from adverse drug events: development and evaluation in a community hospital. JAMA. 1998; 280:1317-20.

69. Reynolds R, Heller E. An academic medical center experience with a computerized hospital information system: the first four years. Proc Annu Symp Comput Appl Med Care. 1980; 4:3-16.

70. Schiff G, Rucker T. Computerized prescribing: building the electronic infrastructure for better medication usage. JAMA. 1998; 279:1024-9.

71. Schiff G, Wisniewski M, Bult J et al. Improving patient antibiotic prescribing: insights from participation in a national collaborative. Jt Comm J Qual Improv. 2001; 27:387-402.

72. Schneider R, LaBatt E. Computerized system for physician order entry. Am J Health-Syst Pharm. 1995; 52:2184-6.

73. Schroeder C, Pierpaoli P. Direct order entry by physicians in a computerized hospital information system. Am J Hosp Pharm. 1986; 43:355-9.

74. Schumock GT, Marwaha TR, McBride JM et al. Automated order-entry mechanisms to influence prescribing. Top Hosp Pharm Manage.1994; 14(3):21-9.

75. Shu K, Boyle D, Spurr CD et al. Comparison of time spent writing orders on paper with computerized physician order entry. Medinfo. 2001; 10(pt. 2): 1207-11.

76. Sittig D, Stead W. Computer-based physician order entry: the state of the art. J Am Med Inform Assoc. 1994; 1:108-23.

77. Spillane M, McLaughlin M, Ellis K et al. Direct physician order entry and integration: potential pitfalls. Proc Annu Symp Comput Appl Med Care. 1990; 14:774-8.

78. Teich J, Glaser J, Beckley R. Toward cost-effective quality care: the Brigham Integrated Computing System. Proc Second Nicholas E. Davies CPR Recog Symp. 1996; 3-34.

79. Teich J, Hurley J, Beckley R et al. Design of an easy-to-use physician order entry system with support for nursing and ancillary departments. Proc Annu Symp Comput Appl Med Care. 1992; 16:99-103.

80. Teich J, Schmiz J, O'Connell E et al. An information system to improve the safety and efficiency of chemotherapy ordering. J Am Med Inform Assoc. 1996; 3(suppl):498-502.

81. Teich J, Spurr C, Flammini SJ et al. Response to a trial of physician-based inpatient order entry. Proc Annu Symp Comput Appl Med Care. 1993; 17:316-20.

82. Teich JM, Glaser JP, Beckley RF et al. The Brigham Integrated Computing System (BICS): advanced clinical systems in an academic hospital environment. Int J Med Inf. 1999; 54:197-208.

83. Teich JM, Spurr CD, Schmiz JL et al. Enhancement of clinician workflow with computer order entry. Proc Annu Symp Comput Appl Med Care. 1995; 459-63.

84. Tierney W. Computerizing guidelines: factors for success. Proc AMIA Annu Fall Symp. 1996; 459-62.

85. Tierney W, Overhage J, McDonald C et al. Medical students' and housestaff's opinions of computerized order-writing. Acad Med. 1994; 69:386-9.

86. Tierney W, Overhage J, Takesue B et al. Computerizing guidelines to improve care and patient outcomes: the example of heart failure. J Am Med Inform Assoc. 1995; 2:316-22.

87. Weiner M, Gress T, Thiemann DR et al. Contrasting views of physicians and nurses about an inpatient computerbased provider order-entry system. J Am Med Inform Assoc. 1999; 6:234-44.

88. Weir C, Lincoln M, Roscoe D et al. Successful implementation of an integrated physician order entry application: a systems perspective. Proc Annu Symp Comput Appl Med Care. 1995; 790-4.

89. Weir C, McCarthy C, Gohlinghorst S et al. Assessing the implementation process. Proc AMIA Symp. 2000; 908-12.

90. Wilson G, McDonald C, McCabe G. The effect of immediate access to a computerized medical record on physician test ordering: a controlled clinical trial in the emergency room. Am J Public Health. 1982; 72:698-702.

91. Young D. CPOE reduces number of steps in medication-use process. Am J Health-Syst Pharm. 2001; 58:1170,1173.

92. Zimmerman M. Provider order entry: it can work! J Emerg Nurs. 1997; 23:463-6.

^aExcluded because of unobtainability.

Sidebar: Appendix B - Excluded Articles Pertaining to Automated Dispensing Machines

1. Barker KN. Ensuring safety in the use of automated medication dispensing systems. Am J Health-Syst Pharm. 1995; 52:2445-7.

2. Barker KN, Harris JA, Webster DB et al. Consultant evaluation of a hospital medication system: implementation and evaluation of the new system. Am J Hosp Pharm. 1984; 41:2022-9.

3. Barker KN, Harris JA, Webster DB et al. Consultant evaluation of a hospital medication system: analysis of the existing system. Am J Hosp Pharm. 1984; 41:2009-16.

4. Barker KN, Harris JA, Webster DB et al. Consultant evaluation of a hospital medication system: implementation and evaluation of the new system. Am J Hosp Pharm. 1984; 41:2022-9.

5. Barker KN, Harris JA, Webster DB et al. Consultant evaluation of a hospital medication system: synthesis of a new system. Am J Hosp Pharm. 1984; 41:2016-21.

6. Botwin K, Chan J, Jacobs R et al. Impact of a 24 hour stop and restricted access to automated dispensing machines upon duration of surgical antibiotic prophylaxis. Am J Health-Syst Pharm. 2001; 58: 797-9.

7. Hurley D. Automated medication system -- benefits for nursing. Proc Annu Symp Comput Appli Med Care. 1994; 51:1050.

8. Ishizuka H, Waki Y, Horizuti M et al. Development and evaluation of a new automated dispensing system. Int J Biomed Comput. 1995; 38(2):167-76.

9. Joint Commission on Accreditation of Healthcare Organizations. Surveying medication use related to automated dispensing machines. www.jcaho.org (accessed 2001 Apr 18).

10. Jones DG, Crane VS, Trussell RG. Automated medication dispensing: the ATC 212 system. Hosp Pharm. 1989; 24: 604,606-10.

11. Landis NT. Automated dispensing systems vary by function, location. Am J Hosp Pharm. 1993; 50:2242-4,2247-8.

12. Magnus GH. Preparing for automated dispensing devices. Am J Health-Syst Pharm. 1995; 52:2406-8.

13. Morrill TS. Automated pharmacy systems: avoiding the pitfalls. Hosp Mat Manage Q. 1982; 4(2):79-85.

14. Novek J, Bettess S, Burke K et al. Nurses' perceptions of the reliability of an automated medication dispensing system. J Nurs Care Qual. 2000; 14(2):1-13.

15. Novek J, Rudnick W. Automatic drug dispensing help or hindrance? Can Nurse. 2000; 96(4):29-33.

16. Oren E, Griffiths LP, Guglielmo J. Characteristics of antimicrobial overrides associated with automated dispensing machines. Am J Health-Syst Phar. 2002; 59:1445-8.

17. Padilla N. Current status of automated dispensing system. Am J Hosp Pharm. 1994; 51:704.

18. Perini VJ, Vermeulen LC Jr. Comparison of automated medication-management systems. Am J Hosp Pharm. 1994; 51:1883-91.

19. Rich D. Automated dispensing machines. Hosp Pharm. 2000; 35:666-70.

20. Ringold DJ, Santell JP, Schneider PJ. ASHP national survey of pharmacy practice in acute care settings: dispensing and administration -- 1999. Am J Health-Syst Pharm. 2000; 57:1759-75.

21. Survey of automated dispensing shows need for practice improvements and safer system design. Huntingdon Valley, PA: Institute for Safe Medication Practices; 1999 Jun 16.

22. Vrabel RB, Mackowiak L. Automation in pharmacy: two institutions' experiences with novel distribution systems. Hosp Formul. 1995; 30(2):106-13.

23. Wong BJ, Rancourt MD, Clark ST. Choosing an automated dispensing machine. Am J Health-Syst Pharm. 1999; 56:1398-9.

^aExcluded because of unobtainability.

Sidebar: Appendix C - Excluded Articles Pertaining to Bar Coding

1. Barhyte D. Bar coding. A new tool for researchers. West J Nurs Res. 1989; 11:347-51.

2. Beer E, Becker R. Specimen collection made easier with bar codes. CAP Today. 1995; 9(19):62,64.

3. Chin T. Identifying new uses for bar coding technology. Health Data Manage. 1999; 7(8):66-8,70-1.

4. Darby P. Bar coding technology in inventory control. Can J Hosp Pharm. 1988; 41:313-6.

5. Ferkovic T. Inventory control systems in the hospital pharmacy. Hosp Mater Manage. 1983; 5(2):70-7.

6. Gandy J. Managing purchasing and inventory with bar codes. Part II. Hosp Mater Manage. 1986; 11(4):8-12.

7. Gandy J. Designing and implementing a bar code system. Hosp Mater Manage. 1986; 11(3):3-9.

8. Garza D, Murdock S, Garcia L et al. Bar codes in the clinical laboratory. Clin Lab Sci. 1991; 4(1):23-5.

9. Hakanson W. Inventory and billing processes using bar coding. J Healthc Mater Manage. 1988; 6(6):57-60.^a

10. Hokanson JA, Guernsey BG, Bryant SG et al. The feasibility of barcode-based dispensing quality assurance programs. Drug Intell Clin Pharm. 1984; 18:76-8.

11. Hokanson JA, Keith MR, Guernsey BG et al. Potential use of bar codes to implement automated dispensing quality assurance programs. Hosp Pharm. 1985; 20:327-9,333,337.

12. Jenis E. Bar codes magnify efficiencies at Millard Fillmore. Healthc Inform. 1992; 9 (3):56,58.

13. Jensen NJ, Crosson JT. An automated system for bedside verification of the match between patient identification and blood unit identification. Transfusion. 1996; 36:216-21.

14. Kaplan R. Materials management with a bar code reader. J Clin Eng. 1990; 15:219-25.

15. Kasten B. What are all those lines and spaces? Understanding bar code technology. MLO Med Lab Obs. 1992; 24(12):25-7.

16. Kasten B, Schrand P, Disney M. Joining the bar code revolution. MLO Med Lab Obs. 1992; 24(12):22-5.

17. Learn H. Bar coding in the microbiology lab. MLO Med Lab Obs. 1995; 27 (5):52-3.

18. Lefkowitz S, Cheiken H, Barnhart MR. A trial of the use of bar code technology to restructure a drug distribution and administration system. Hosp Pharm. 1991; 26:239-42.

19. Longe K. Bar coding. The inventory manager. J Healthc Mater Manage. 1987; 5(4):37-40.

20. Longe KM. Bar codes in health information management: status, standards, and selections. Top Health Rec Manage. 1992; 12(3):12-9.

21. Longe KM. The status of bar coding in hospitals: a survey report. Hosp Technol Ser. 1989; 8(5):1-42.

22. Maffetone MA, Watt SW, Whisler KE. Automated sample handling in a clinical laboratory. Comput Healthc. 1988; 9(9):48-50.

23. Maine C. Bar code tracking system boosts performance of labour management system. Health Estate J. 1994; 48(9):3-4.^[a]

24. Martin E. Barcode is better, bar none. Healthc Inform. 1995; 12(3):88,90.

25. Mudie D. Bar coding in a medical records department: a case study. Hosp Technol Ser. 1988; 7(11):1-15.

26. Noordegraaf G, Bouman J, van den Brink E et al. Development of computer-assisted patient control for use in the hospital setting during mass casualty incidents. Am J Emerg Med. 1996; 14:257-61.

27. Paul N. Admission to discharge. Tracking a patient's progress using wireless bar coding. Health Manage Technol. 2001; 22(2):30,32.

28. Post C. Can bar codes manage EMS inventory? Emerg Med Serv. 2000; 29(11):100.

29. Puckett F. Medication-management component of a point-of-care information system. Am J Health-Syst Pharm. 1995; 52:1305-9.

30. Renner SW, Howanitz PJ, Bachner P. Wristband identification error reporting in 712 hospitals. A College of American Pathologists' q-probes study of quality issues in transfusion practice. Arch Pathol Lab Med. 1993; 117:573-7.

31. Ritt E, Agase E. Bar coding makes its hospital debut. Nurs Manage. 1988; 19(7):44-5.

32. Schmaus D. The basics of bar code technology. AORN J. 1991; 53:1542-8.

33. Scott M, McElnay J, Burnett K. Using bar-code technology to capture clinical intervention data in a hospital with a stand-alone pharmacy computer system. Am J Health-Syst Pharm. 1996; 53:651-4.

34. Shimkus J. Quick scan . . . bar codes deliver the goods. Mater Manage Health Care. 1997; 6(10):26-8.

35. Swift T. Bar coding. Cornerstone of information collection and processing. Comput Healthc. 1985; 6(13):29-30.

36. Tilzer LL, Jones RW. Use of bar code labels on collection tubes for specimen management in the clinical laboratory. Arch Pathol Lab Med. 1988; 112:1200-02.

37. Weilert M, Tilzer L. Putting bar codes to work for improved patient care. Clin Lab Med. 1991; 11:227-38.

38. Zarowitz BJ, Petitta A, Mlynarek M et al. Bar-code technology applied to drug-use evaluation. Am J Hosp Pharm. 1993; 50:935-9.

39. Zarowitz BJ, Petitta A, Rudis MI et al. Bar code documentation of pharmacotherapy services in intensive care units. Pharmacotherapy. 1996; 16:261-6.

Sidebar: Appendix D - Excluded Articles Pertaining to Computerized Medication Administration Records

1. Barcia SM. Implementing pharmacy computer systems. Health Manage Technol. 1999; 20(7):22-3.^[a]

2. Cherici CA, Remillard P. Implementation of a computerized medication administration record. Hosp Pharm. 1993; 28:193-5,198-205.

3. Childs SA, Poikonen J. Converting from manual to computerized medication administration records. Am J Hosp Pharm. 1993; 50:1420-2.

4. Dodge M. What works. Computerized records reduce paperwork, improve productivity. Health Manage Technol. 1999; 20(2):14-5.^[a]

5. Grabowski BS. Pharmacy-based automated medication records: methods, application, and a survey of use. Top Hosp Pharm Manage. 1994; 14(3):58-72.

6. McFall EL. An electronic medical record -- delivering benefits today. Healthc Inform. 1993; 10(10):76,78.

7. Murray D. Electronic records solved this practice's problems. Med Econ. 1996; 73(10):135-6,142-4,147.

8. Wilson AL, Hill JJ, Wilson RG et al. Computerized medication administration records decrease medication occurrences. Pharm Pract Manage Q. 1997; 17(1):17-29.

^aExcluded because of unobtainability.