a qualitative study identified 22 types of medication error risks facilitated by the use of a CPOE system. Examples included patient or medication selection errors due to fragmented CPOE displays preventing a coherent view of patients’ details and medications, pharmacy inventory displays mistaken for dosage guidelines, ignored antibiotic renewal notices placed on paper charts rather than in the CPOE system, medication discontinuation failures, immediate orders and pro re nata (PRN) medication discontinuation faults, double dosing and incompatible orders facilitated by separation of functions, and wrong orders due to inflexible ordering formats.