Computer-related medication errors in neonatal intensive care units

Computerized Physician Order Entry in the Neonatal Intensive Care Unit: A Narrative Review

BACKGROUND

Computerized physician order entry (CPOE) has grown since the early 1990s. While many systems serve adult patients, systems for pediatric and neonatal populations have lagged. Adapting adult CPOE systems for pediatric use may require significant modifications to address complexities associated with pediatric care such as daily weight changes and small medication doses.

OBJECTIVE

This article aims to review the neonatal intensive care unit (NICU) CPOE literature to characterize trends in the introduction of this technology and to identify potential areas for further research.

METHODS

Articles pertaining to NICU CPOE were identified in MEDLINE using MeSH terms "medical order entry systems," "drug therapy," "intensive care unit, neonatal," "infant, newborn," etc. Two physician reviewers evaluated each article for inclusion and exclusion criteria. Consensus judgments were used to classify the articles into five categories: medication safety, usability/alerts, clinical practice, clinical decision Support (CDS), and implementation. Articles addressing pediatric (nonneonatal) CPOE were included if they were applicable to the NICU setting.

RESULTS

Sixty-nine articles were identified using MeSH search criteria. Twenty-two additional articles were identified by hand-searching bibliographies and 6 articles were added after the review process. Fifty-five articles met exclusion criteria, for a final set of 42 articles. Medication safety was the focus of 22 articles, followed by clinical practice (10), CDS (10), implementation (11), and usability/alerts (4). Several addressed more than one category. No study showed a decrease in medication safety post-CPOE implementation. Within clinical practice articles, CPOE implementation showed no effect on blood glucose levels or time to antibiotic administration but showed conflicting results on mortality rates. Implementation studies were largely descriptive of single-hospital experiences.

CONCLUSION

CPOE implementation within the NICU has demonstrated improvement in medication safety, with the most consistent benefit involving a reduction in medication errors and wrong-time administration errors. Additional research is needed to understand the potential limitations of CPOE systems in neonatal intensive care and how CPOE affects mortality.

Using Health Information Technology to Improve Safety in Neonatal Care: A Systematic Review of the Literature

Health information technology (HIT) interventions may improve neonatal patient safety but may also introduce new errors. The objective of this review was to evaluate the evidence for use of HIT interventions to improve safety in neonatal care. Evidence for improvement exists for interventions like computerized provider order entry in the neonatal population, but is lacking for several other interventions. Many unique applications of HIT are emerging as technology and use of the electronic health record expands. Future research should focus on the impact of these interventions in the neonatal population.

Examining Perceptions of Computerized Physician Order Entry in a Neonatal Intensive Care Unit

BACKGROUND

Computerized provider order entry (CPOE) is a technology with potential to transform care delivery. While CPOE systems have been studied in adult populations, less is known about the implementation of CPOE in the neonatal intensive care unit (NICU) and perceptions of nurses and physicians using the system.

OBJECTIVE

To examine perceptions of clinicians before and after CPOE implementation in the NICU of a pediatric hospital.

METHODS

A cross-sectional survey of clinicians working in a Level III NICU was conducted. The survey was distributed before and after CPOE implementation. Participants were asked about their perception of CPOE on patient care delivery, implementation of the system, and effect on job satisfaction. A qualitative section inquired about additional concerns surrounding implementation. Responses were tabulated and analyzed using the Chi-square test.

RESULTS

The survey was distributed to 158 clinicians with a 47% response rate for pre-implementation and 45% for post-implementation. Clinicians understood why CPOE was implemented, but felt there was incomplete technical training. The expectation for increased job satisfaction and ability to recruit high-quality staff was high. However, there was concern about the ability to deliver appropriate treatments before and after implementation. Physicians were more optimistic about CPOE implementation than nurses who remained concerned that workflow may be altered.

CONCLUSIONS

Introducing CPOE is a potentially risky endeavor and must be done carefully to mitigate harm. Although high expectations of the system can be met, it is important to attend to differing expectations among clinicians with varied levels of comfort with technology. Interdisciplinary collaboration is critical in planning a functioning CPOE to ensure that efficient workflow is maintained and appropriate supports for individuals with a lower degree of technical literacy is available.

EHR-related medication errors in two ICUs

The objective of this study was to describe the frequency, potential harm, and nature of electronic health record (EHR)-related medication errors in intensive care units (ICUs). Using a secondary data analysis of a large database of medication safety events collected in a study on EHR technology in ICUs, we assessed the EHR relatedness of a total of 1622 potential preventable adverse drug events (ADEs) identified in a sample of 624 patients in 2 ICUs of a medical center. Thirty-four percent of the medication events were found to be EHR related. The EHR-related medication events had greater potential for more serious patient harm and occurred more frequently at the ordering stage as compared to non-EHR-related events. Examples of EHR-related events included orders with omitted information and duplicate orders. The list of EHR-related medication errors can be used by health care delivery organizations to monitor implementation and use of the technology and its impact on patient safety. Health information technology (IT) vendors can use the list to examine whether their technology can mitigate or reduce EHR-related medication errors.

ICU 2020: five interventions to revolutionize quality of care in the ICU

Intensive care units (ICUs) are an essential and unique component of modern medicine. The number of critically ill individuals, complexity of illness, and cost of care continue to increase with time. In order to meet future demands, maintain quality, and minimize medical errors, intensivists will need to look beyond traditional medical practice, seeking lessons on quality assurance from industry and aviation. Intensivists will be challenged to keep pace with rapidly advancing information technology and its diverse roles in ICU care delivery. Modern ICU quality improvement initiatives include ensuring evidence-based best practice, participation in multicenter ICU collaborations, employing state-of-the-art information technology, providing point-of-care diagnostic testing, and efficient organization of ICU care delivery. This article demonstrates that each of these initiatives has the potential to revolutionize the quality of future ICU care in the United States.

Receptionist input to quality and safety in repeat prescribing in UK general practice: ethnographic case study

OBJECTIVE

To describe, explore, and compare organisational routines for repeat prescribing in general practice to identify contributors and barriers to safety and quality.

DESIGN

Ethnographic case study.

SETTING

Four urban UK general practices with diverse organisational characteristics using electronic patient records that supported semi-automation of repeat prescribing.

PARTICIPANTS

395 hours of ethnographic observation of staff (25 doctors, 16 nurses, 4 healthcare assistants, 6 managers, and 56 reception or administrative staff), and 28 documents and other artefacts relating to repeat prescribing locally and nationally.

MAIN OUTCOME MEASURES

Potential threats to patient safety and characteristics of good practice.

METHODS

Observation of how doctors, receptionists, and other administrative staff contributed to, and collaborated on, the repeat prescribing routine. Analysis included mapping prescribing routines, building a rich description of organisational practices, and drawing these together through narrative synthesis. This was informed by a sociological model of how organisational routines shape and are shaped by information and communications technologies. Results Repeat prescribing was a complex, technology-supported social practice requiring collaboration between clinical and administrative staff, with important implications for patient safety. More than half of requests for repeat prescriptions were classed as "exceptions" by receptionists (most commonly because the drug, dose, or timing differed from what was on the electronic repeat list). They managed these exceptions by making situated judgments that enabled them (sometimes but not always) to bridge the gap between the idealised assumptions about tasks, roles, and interactions that were built into the electronic patient record and formal protocols, and the actual repeat prescribing routine as it played out in practice. This work was creative and demanded both explicit and tacit knowledge. Clinicians were often unaware of this input and it did not feature in policy documents or previous research. Yet it was sometimes critical to getting the job done and contributed in subtle ways to safeguarding patients. Conclusion Receptionists and administrative staff make important "hidden" contributions to quality and safety in repeat prescribing in general practice, regarding themselves accountable to patients for these contributions. Studying technology-supported work routines that seem mundane, standardised, and automated, but which in reality require a high degree of local tailoring and judgment from frontline staff, opens up a new agenda for the study of patient safety.

Electronic prescribing and prescription design in ophthalmic practice

PURPOSE

Prescription and drug errors are common causes of adverse clinical events, posing a significant risk to safe patient care. Although there has been a movement to increase the use of electronic prescribing, concerns over feasibility suggest that improving the design of written prescriptions to minimize missing information may still be worthwhile. This retrospective cross-sectional study examined the effect on prescription completeness of electronic prescriptions and adding information prompts to written prescriptions. We hypothesized that electronic prescription would be superior to written prescriptions on prescription completeness and the inclusion of information prompts in written prescriptions would result in increased recording of the prompted information.

METHODS

Chi-square analysis was used to examine differences among 50 consecutive electronic discharge prescriptions, 100 consecutive outpatient prescriptions (with prompts for medicine duration but not form, frequency, or laterality), and 100 consecutive day surgery prescriptions (with prompts for form, frequency, and laterality) in the provision of 10 key pieces of information.

RESULTS

Electronic prescriptions resulted in 100% complete information across all domains and more complete information on medicine duration than day surgery prescriptions. Written outpatient prescriptions (with duration prompts but not laterality prompts) were superior in recording duration and inferior in recording laterality than day surgery prescriptions (without duration prompts but with laterality prompts).

CONCLUSIONS

Our results support the use of electronic prescribing. Where written prescribing must be used, our study highlights the importance of including information prompts to minimize missing information and improve patient safety.

Neonatal Informatics: Computerized Physician Order Entry

Computerized physician order entry (CPOE) is the feature of electronic medical record (EMR) implementation that arguably offers the greatest quality and patient safety benefits. The gains are potentially greater for critically ill neonates, but the effect of CPOE on quality and safety is dependent upon local implementation decisions. OBJECTIVES: After completing this article, readers should be able to: Define the basic aspects of CPOE and clinical decision support (CDS) systems.Describe the potential benefits of implementing CPOE associated with CDS in a neonatal intensive care unit (NICU).

Medication errors resulting from computer entry by nonprescribers

PURPOSE

The characteristics of medication errors associated with the use of computer order-entry systems by nonprescribers are discussed.

METHODS

A retrospective analysis of records submitted to MEDMARX was conducted for the period from July 1, 2001, to December 31, 2005, to identify all computer-related medication errors made by nonprescribers. Quantitative analysis of the records included the severity of each error, the origin within the medication-use process, the type of error, principal causes, the location within the facility where the error was made, and the therapeutic drug classes frequently involved. Similar data from the University of Pittsburgh Medical Center (UPMC) were also analyzed and compared with the national data set.

RESULTS

During the 4.5 years, 693 unique facilities submitted 90,001 medication error records that were the result of computer entry by nonprescribers. The national data set and the UPMC data had similar findings for error severity, error origin, and type of error but showed some differences in the rank ordering of error causes, location where the error occurred, and drug classes frequently associated with such errors. The percentage of harm associated with computer-entry errors was small for both the national data set and UPMC data (0.99% and 0.80%, respectively). Both data sets cited performance deficit as the leading cause of computer-entry errors, but large percentage differences were seen with other causes, including inaccurate or omitted transcription (30% versus 12.6%, respectively), documentation (19.5% versus 10.6%, respectively), and procedure or protocol not followed (21.7% versus 30.3%, respectively). Both data sets implicated the inpatient pharmacy department as the location where most computer-entry errors occurred (49.3% versus 69.0%, respectively).

CONCLUSION

Analysis of the characteristics of medication errors associated with the use of computer-entry systems by non-prescribers from both MEDMARX and an individual health system database demonstrated that computer systems create new opportunities for errors to occur. Working closely with information technology personnel dedicated to assisting pharmacy departments and vendors, adequate training of pharmacy staff, and development of national standards for drug information displays in computer order-entry systems may help minimize such errors.