Clinical literature had noted that most medication errors occur at the prescribing phase of the medication use process.1,10 There are mixed conclusions regarding the effectiveness of computerized physician order entry (CPOE) systems to reduce medication errors. The implementation of CPOEs has been shown to minimize the incidence of medication errors.11-17 However, it has also been suggested that the positive benefits of CPOE can be compromised by human–computer interaction. Horsky et al18 described a prescribing error that led to patient overdosing on intravenous (IV) potassium. The error occurred because the prescriber failed to include an appropriate discontinuation time on a previous order. It has also been noted that inappropriate user training, inconsistent behavior in data entry fields, or unfamiliarity with system operations are common root causes that contribute to medication orders.18 Horsky et al also cite various examples of CPOEgenerated errors such as key-pad entry (typographical error), drop-down menu (wrong selection from drop-down box), and duplicate medication (2 orders written for the same medication due an absence of a flagging system).