Unexpected Drawbacks of Electronic Order Sets
A transition from paper orders to CPOE left out an important safety reminder, resulting in mismanagement of an elderly patient's low potassium and magnesium levels. This led to a fatal arrhythmia. The paper-based electrolyte order set had provided a reminder that magnesium replacement should accompany potassium replacement; however, in the computerized system, a separate order set was necessary for each electrolyte. In the accompanying commentary, John D. McGreevey III, MD, of the University of Pennsylvania, discusses the benefits and limitations of order sets and the importance of clinicians maintaining a trust-but-verify approach to decision support systems.