Implementation of computerized physician order entry (CPOE) systems can be problematic owing to disruption of provider work flow, as illustrated in prior research. In this study, a CPOE system was integrated within an existing clinical information system at an academic medical center. This approach is described as an "intermediate step" to improve safety without incurring the expense of an entirely new system. The authors describe the implementation process, which focused on identifying and addressing user concerns before fully implementing the new system. Despite these efforts, prescribing errors initially increased during the pilot phase, but, after full implementation, prescribing errors were significantly reduced. Another study of successful implementation of a different CPOE system also demonstrated the importance of minimizing disruption of provider work flow.