The lionized axiom of Mick and Co. holds true, it seems, for one of the sacred cows of healthcare IT and EHR/HIE: CPOE. 

Because it is incumbent upon CPOE software to scrutinize a patient’s record for drug contraindications and flag deleterious combinations for the prescribing physician, UPenn MS’s Dr. Brian Strom chose to modify the school’s CPOE by adding a “nearly hard stop” (in addition to soft and hard stops that are coded into CPOE) and tried testing it in the field.

The upshot? An unintended consequence. While causing no harm, this safer-care sentry delayed a small percentage of patient treatment, which could have been detrimental in its own right. However, the modification did succeed in reducing instances of accidental drug contraindications, a legitimate hedge against perhaps the greater threat.

The moral? “If you try, try, try, you just might find, you get what you need” – safer patient care. Here’s the detail from UPenn Med School.