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This example of a disaster waiting to happen, in the form of an error-promoting CPOE, is a poster example of why the net of litigation needs to be cast far wider than just clinicians when EHR-related errors result in injury or death.

This order entry screen, from a production system shows the following.  In all fairness, I do note it’s unclear if the vendor or the customer’s configuration “experts” were responsible for this:

COUMADIN (warfarin) tablet 2 mg Oral daily once.
CAUTION: Potential look-Alike or Sound-Alike medication – this product is COUMADIN

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