 Results: There were 3 reported incidents of errors among 13,124 CPR medications orders during the year preceding implementation of CPOECDSS. These represent errors that escaped the triple check by three independent staff members two nurses and one physician. There was an average of 11.6 errors100 orders in the simulated CPR form and potential ADEs occurred at a rate of 11.3100 orders and MPEs at a rate of 0.3100 orders. There were no errors after CPOECDSS was implemented 100 error reduction. Time to completion of drug forms dropped from 14 min 42 sec to 2 min 14 sec p0.001. 