JMIR Publications

ABSTRACT

Background:

The consequences of medication errors are substantial as they pose a significant threat to the high-risk population, including paediatric, neonatal and geriatric patients. Computerised Provider Order Entry (CPOE) systems and clinical decision support systems (CDSS) are increasingly implemented to reduce medical errors by automating prescribing processes and providing real-time decision support. While alerts have been shown to provide value, barriers to widespread implementation exist in the form of alert fatigue and usability problems.

Objective:

This systematic review and meta-analysis assessed the effectiveness of CPOE and CDSS in reducing medication errors across diverse populations and clinical environments.

Methods:

A systematic review was conducted following the Preferred Items for Systematic Review and meta-analyses (PRISMA guidelines), with four databases searched up to February 2025 for studies evaluating the effects of CPOE and CDSS implementation on medication error in paediatric and geriatric populations. We included only cohort and prospective studies, not restricted by language or country of publication. Single measures of continuous outcomes on medication error rates were extracted from each study. The Comprehensive Meta-analysis (CMA) was then applied to perform separate analyses to compare the outcome pre-and post-CPOE/CDSS implementation. A random-effect meta-analysis was conducted, with subgroup analyses to assess differences by population, healthcare setting, and system design. The Newcastle–Ottawa Scale was used for quality appraisal. Forest plots and funnel plots were applied for pooled results and publication bias assessment.

Results:

Fourteen studies met the inclusion criteria (paediatric: n = 12; geriatric: n = 2), all rated as good quality. In paediatrics, 10 of 12 studies reported significant reductions in medication errors post-implementation. Pooled analysis showed error rates were almost threefold higher pre-implementation (OR = 2.97; 95% CI 2.81–3.14), with substantial heterogeneity (I² = 94%) but consistent positive direction of effect. In geriatrics, both studies demonstrated significant reductions with no heterogeneity (I² = 0%) (OR = 2.45; 95% CI 2.29–2.62), though evidence remains limited in scope and setting due to the small number of studies. Descriptive synthesis indicated that CPOE/CDSS can intercept high severity errors, such as overdoses of high-risk medications, before reaching patients, although most studies assessed potential rather than actual harm. Meta‑regression showed study location as a significant moderator, with greater effects in North American studies compared to those conducted in Asia. No publication bias was detected, but regional variation suggests contextual factors such as healthcare infrastructure, informatics maturity and influence system effectiveness.

Conclusions:

CPOE/CDSS significantly reduces medication errors in special populations, with strong and consistent benefits in paediatrics and promising but limited evidence in geriatrics. Despite heterogeneity in paediatric studies, the direction of effect was uniformly positive. The systems also show potential to reduce the severity of harmful errors, although robust evidence on actual patient harm is lacking. Optimising and tailoring CPOE/CDSS to specific patient populations and healthcare settings, while addressing alert fatigue and workflow integration, are essential to maximise impact. Further research should expand the geriatric and neonatal evidence base, assess long-term outcomes and explore advanced decision support capabilities to enhance patient safety and clinical impact.