CPOE and the facilitation of medication errors

Impact of a computerized physician order entry system on compliance with prescription accuracy requirements

OBJECTIVE

To assess the change in non-compliant items in prescription orders following the implementation of a computerized physician order entry (CPOE) system named PreDiMed.

SETTING

The department of internal medicine (39 and 38 beds) in two regional hospitals in Canton Vaud, Switzerland.

METHOD

The prescription lines in 100 pre- and 100 post-implementation patients' files were classified according to three modes of administration (medicines for oral or other non-parenteral uses; medicines administered parenterally or via nasogastric tube; pro re nata (PRN), as needed) and analyzed for a number of relevant variables constitutive of medical prescriptions.

MAIN OUTCOME MEASURE

The monitored variables depended on the pharmaceutical category and included mainly name of medicine, pharmaceutical form, posology and route of administration, diluting solution, flow rate and identification of prescriber.

RESULTS

In 2,099 prescription lines, the total number of non-compliant items was 2,265 before CPOE implementation, or 1.079 non-compliant items per line. Two-thirds of these were due to missing information, and the remaining third to incomplete information. In 2,074 prescription lines post-CPOE implementation, the number of non-compliant items had decreased to 221, or 0.107 non-compliant item per line, a dramatic 10-fold decrease (chi(2) = 4615; P < 10(-6)). Limitations of the computerized system were the risk for erroneous items in some non-prefilled fields and ambiguity due to a field with doses shown on commercial products.

CONCLUSION

The deployment of PreDiMed in two departments of internal medicine has led to a major improvement in formal aspects of physicians' prescriptions. Some limitations of the first version of PreDiMed were unveiled and are being corrected.

Analysis of overridden alerts in a drug-drug interaction detection system

OBJECTIVE

The aim of this study was to evaluate the relevance of the signals generated by a computerized drug-drug interaction detection system and to design a classification of overridden drug-drug interaction alerts.

STUDY DESIGN

Prospective study over two months.

SETTING

Five hundred and ten-bed university paediatric hospital.

MAIN OUTCOME MEASURES

In Robert Debré Hospital physicians generate drug orders online using a computerized physician order entry system that also detects drug-drug interactions in real time. We analysed the relevance of a sample of alerts overridden by physicians.

RESULTS

We analysed a sample of 613 overridden alerts. We defined three categories of overridden alerts: informational errors (35); system errors (244) and accurate alerts (334). Two reasons account for 40% of false-positive alerts: an inability of the system to recognize real conflicts between drug treatments and guidelines stating that the two drugs can be used together, because the benefit outweighs the risk of side effects due to the drug-drug interaction.

CONCLUSIONS

We created a classification of overridden alerts, in the context of computerized physician order entry system coupled with a drug-drug interaction detection system. There is clearly room for improvement in the development of drug-drug interaction software. This classification should make it possible to break this work down into smaller tasks, making it possible to decrease the sensitivity to background noise of drug-drug interaction detection systems.

Attending unintended transformations of health care infrastructure

INTRODUCTION

Western health care is under pressure from growing demands on quality and efficiency. The development and implementation of information technology, IT is a key mean of health care authorities to improve on health care infrastructure.

THEORY AND METHODS

Against a background of theories on human-computer interaction and IT-mediated communication, different empirical studies of IT implementation in health care are analyzed. The outcome is an analytical discernment between different relations of communication and levels of interaction with IT in health care infrastructure. These relations and levels are synthesized into a framework for identifying tensions and potential problems in the mediation of health care with the IT system. These problems are also known as unexpected adverse consequences, UACs, from IT implementation into clinical health care practices.

RESULTS

This paper develops a conceptual framework for addressing transformations of communication and workflow in health care as a result of implementing IT.

CONCLUSION AND DISCUSSION

The purpose of the conceptual framework is to support the attention to and continuous screening for errors and unintended consequences of IT implementation into health care practices and outcomes.

Unintended transformations of clinical relations with a computerized physician order entry system

A socio-technical approach was used to study the qualitative effects of deploying a medication computerized physician order entry system (CPOE with no decision support) at two internal medical wards in a hospital in Denmark. Our results show spatial and temporal transformations of core acts and relations in medication work, i.e. of the intended use of the system inscribed in hardware and software, in the relations of care between doctors and patients, of collaboration between doctors and nurses, and prospectively of the patients' trajectories when readmitted to hospital or another health care institution, reusing data from the system. This study throws light on problems of continuity of patient care paths, patient-related and IT-system-related error handling and time spent on core activities--when ubiquitous IT is used locally in a real physical setting with specific traditions of performing or 'doing medication'. The paper argues for the project organization to support the local collaboration and renegotiation of time and place of enacting medication with CPOE, as well as set up feedback for maturation of the software for future clinical use.