Preprinted order sets as a safety intervention in pediatric sedation

An initiative to reduce medication errors in neonatal care unit of a tertiary care hospital, Kolkata, West Bengal: a quality improvement report

Background

Medication errors are an emerging problem in various hospital settings, especially in neonates. A study conducted in the neonatal care unit of a tertiary institute in Kolkata as baseline over 3 months, revealed total error to be around 71.1/100 prescriptions (median medication error percentage: 63%).

Purpose

To assess the occurrences of medication errors and determine efficacy of Point-of-Care Quality improvement (POCQI) model in reducing the same from baseline 63% to less than 10%, in the above setting within next 9 months.

Materials and methods

This quality improvement initiative of quasi-experimental design comprised randomly selected prescriptions and monitoring sheets of neonates admitted in the neonatal care unit, obeying inclusion and exclusion criteria. Medication errors were assessed and categorised using a predesigned and pretested checklist. Interventions were planned after forming a quality improvement team in four plan–do–study–act (PDSA) cycles spanning over 6 weeks each (including training of doctors and nurses, signature and countersignatures of respective healthcare personnel, computer-generated prescriptions and newly designed software-generated prescriptions) as per POCQI model of the WHO and results in post-intervention phase (3 months) were compared.

Results

A total of 552 prescriptions and monitoring sheets of 124 neonates were studied. Median medication error percentages in first, second, third and fourth PDSA cycle were, respectively, 48%, 42%, 30% and 14%. Total error reduced to 10.4/100 prescriptions (p<0.005), with significant reduction in erred dosage, timing, interval, preparation and rate of infusion of drugs in prescriptions of the post-intervention phase.

Conclusion

Implementation of change ideas via PDSA cycles, as per the POCQI model with technological aid, significantly decreased the percentage of medication errors in neonates, which was also sustained in the post-intervention phase and facilitated error-free prescriptions.

Risk factors associated with medication ordering errors

OBJECTIVE

We utilized a computerized order entry system-integrated function referred to as "void" to identify erroneous orders (ie, a "void" order). Using voided orders, we aimed to (1) identify the nature and characteristics of medication ordering errors, (2) investigate the risk factors associated with medication ordering errors, and (3) explore potential strategies to mitigate these risk factors.

MATERIALS AND METHODS

We collected data on voided orders using clinician interviews and surveys within 24 hours of the voided order and using chart reviews. Interviews were informed by the human factors-based SEIPS (Systems Engineering Initiative for Patient Safety) model to characterize the work systems-based risk factors contributing to ordering errors; chart reviews were used to establish whether a voided order was a true medication ordering error and ascertain its impact on patient safety.

RESULTS

During the 16-month study period (August 25, 2017, to December 31, 2018), 1074 medication orders were voided; 842 voided orders were true medication errors (positive predictive value = 78.3 ± 1.2%). A total of 22% (n = 190) of the medication ordering errors reached the patient, with at least a single administration, without causing patient harm. Interviews were conducted on 355 voided orders (33% response). Errors were not uniquely associated with a single risk factor, but the causal contributors of medication ordering errors were multifactorial, arising from a combination of technological-, cognitive-, environmental-, social-, and organizational-level factors.

CONCLUSIONS

The void function offers a practical, standardized method to create a rich database of medication ordering errors. We highlight implications for utilizing the void function for future research, practice and learning opportunities.

Orientation in Perpetuity: An Online Clinical Decision Support System for Surgical Residents

BACKGROUND

Limiting variability is an essential element to improving quality of care. Frequent resident turnover represents a significant barrier to clinical standardization. Trainees joining new surgical services must familiarize themselves with the guidelines and protocols that direct patient care as well as their learning objectives and expectations. A clinical decision support system (CDSS) is a dynamic, searchable electronic resource intended for use at the point of care. The CDSS can provide convenient and timely access to relevant information for residents, allowing them to incorporate the most up-to-date protocols and guidelines in their daily care of patients. The objective of this quality improvement intervention was to determine the objective rate of CDSS utilization and its subjective value to residents.

MATERIALS AND METHODS

An internally developed, web-based CDSS including essential, clinically useful documents was created for use by trainees on a busy pediatric surgery service. A standardized orientation was provided to each resident and fellow on joining the service, complemented by a summary card to be attached to the trainee's ID badge. CDSS usage was monitored using web analytics. Trainees who rotated before and after the CDSS launch were surveyed regarding attitudes toward clinical resources and confidence in patient management.

RESULTS

Documents published to the CDSS included 33 clinical guideline documents and 207 additional educational and support files including reference materials from service orientation were made available to trainees and staff. Goals for resident usage were established by evaluation and adaptation of early traffic patterns. Analysis of web traffic collected over 14 consecutive months revealed utilization above target levels, with 4.0 average weekly page views per trainee (IQR: 1.6-5.6). A total of 60 survey responses were received (54% of trainees invited); majorities of rotating trainees and survey respondents were trainees in general surgery and most were interns. Mean composite scores reflected a trend toward improved satisfaction when seeking CDSM (before intervention 3.18 [SD 0.73], after intervention 3.92 [SD 0.70], range 1-5) which was statistically significant (P = 0.005). Mean scores also improved across five of six components of the composite score (mean improvement 0.75, range: 0.53-0.92), four of which were statistically significant (P = 0.001-0.038). Most (59%) respondents reported that they used the CDSS frequently.

CONCLUSIONS

Convenient access to a CDSS resulted in greater than expected utilization as well as higher resident satisfaction with and confidence in materials provided. A CDSS is a promising tool offering quick access to high-quality information in challenging trainee environments.

Improving Guideline Compliance and Documentation Through Auditing Neonatal Resuscitation

Objective: Evaluate whether weekly audits of neonatal resuscitation using video and physiological parameter recordings improved guideline compliance and documentation in medical records. Study design: Neonatal care providers of the Neonatal Intensive Care Unit (NICU) of Leiden University Medical Center reviewed recordings of neonatal resuscitation during weekly plenary audits since 2014. In an observational pre-post cohort study, we studied a cohort of infants born before and after implementation of weekly audits. Video and physiological parameter recordings of infants needing resuscitation were analyzed. These recordings were compared with the prevailing resuscitation guideline and corresponding documentation in the medical record using a pre-set checklist. Results: A total of 212 infants were included, 42 before and 170 after implementation of weekly audits, with a median (IQR) gestational age of 30 (27-35) weeks vs. 30 (29-33) weeks (p = 0.64) and birth weight of 1368 (998-1780) grams vs. 1420 (1097-1871) grams (p = 0.67). After weekly audits were implemented, providers complied more often to the guideline (63 vs. 77%; p < 0.001). Applying the correct respiratory support based on heart rate and respiration, air conditions (dry vs. humidified air), fraction of inspired oxygen (FiO₂), timely start of interventions and evaluation of delivered care improved. Total number of correctly documented items in medical records increased from 39 to 65% (p < 0.001). Greatest improvements were achieved in documentation of present providers, mode of respiratory support and details about transport to the NICU. Conclusion: Regular auditing using video and physiological parameter recordings of infants needing resuscitation at birth improved providers' compliance with resuscitation guideline and documentation in medical records.

Prescriptions for Bedtime Sedatives After the Introduction of a General Admission Order Set at an Academic Health Center: The Potential and Pitfalls of Order Sets

OBJECTIVE

This study describes the impact of modifications to a general admission order set on physician prescribing of 2 as-needed or pro re nata (PRN) bedtime sedatives.

METHODS

The hospitalists at our institution have used a general medical admission order set since 2005. Zolpidem was the only as-needed (PRN) bedtime sedative option on the order set until trazodone was added in December 2008. Trazodone is preferred over zolpidem in the geriatric population. We identified patients admitted by the hospitalists between January 2007 and August 2013 who were prescribed with either zolpidem or trazodone as a PRN sedative. Patient demographics, date and time of the order, and number of sedative doses administered during the hospitalization were recorded. Orders placed within 12 hours of admission were attributed to admission orders.

RESULTS

Between 2007 and 2013, the number of patients admitted by the hospitalists with an order for PRN trazodone on admission increased by 18-fold. During the same period, the number of admissions by the hospitalists increased by 2.3 times. Zolpidem orders exceeded those for trazodone in all age groups until 2008. After the addition of trazodone, its use exceeded that of zolpidem. Almost half (48%) of all patients did not have a dose of the PRN trazodone administered.

CONCLUSIONS

Although order sets can be leveraged to align practitioners with established guidelines, the expediency of using medications on an order set may overcome physicians' clinical judgment. The content of an order set therefore deserves careful scrutiny before implementation.

Pediatric Medication Safety in the Emergency Department

Pediatric patients cared for in emergency departments (EDs) are at high risk of medication errors for a variety of reasons. A multidisciplinary panel was convened by the Emergency Medical Services for Children program and the American Academy of Pediatrics Committee on Pediatric Emergency Medicine to initiate a discussion on medication safety in the ED. Top opportunities identified to improve medication safety include using kilogram-only weight-based dosing, optimizing computerized physician order entry by using clinical decision support, developing a standard formulary for pediatric patients while limiting variability of medication concentrations, using pharmacist support within EDs, enhancing training of medical professionals, systematizing the dispensing and administration of medications within the ED, and addressing challenges for home medication administration before discharge.

Interventions to reduce medication errors in neonatal care: a systematic review

Background

Medication errors represent a significant but often preventable cause of morbidity and mortality in neonates. The objective of this systematic review was to determine the effectiveness of interventions to reduce neonatal medication errors.

Methods

A systematic review was undertaken of all comparative and noncomparative studies published in any language, identified from searches of PubMed and EMBASE and reference-list checking. Eligible studies were those investigating the impact of any medication safety interventions aimed at reducing medication errors in neonates in the hospital setting.

Results

A total of 102 studies were identified that met the inclusion criteria, including 86 comparative and 16 noncomparative studies. Medication safety interventions were classified into six themes: technology (n = 38; e.g. electronic prescribing), organizational (n = 16; e.g. guidelines, policies, and procedures), personnel (n = 13; e.g. staff education), pharmacy (n = 9; e.g. clinical pharmacy service), hazard and risk analysis (n = 8; e.g. error detection tools), and multifactorial (n = 18; e.g. any combination of previous interventions). Significant variability was evident across all included studies, with differences in intervention strategies, trial methods, types of medication errors evaluated, and how medication errors were identified and evaluated. Most studies demonstrated an appreciable risk of bias. The vast majority of studies (>90%) demonstrated a reduction in medication errors. A similar median reduction of 50-70% in medication errors was evident across studies included within each of the identified themes, but findings varied considerably from a 16% increase in medication errors to a 100% reduction in medication errors.

Conclusion

While neonatal medication errors can be reduced through multiple interventions aimed at improving the medication use process, no single intervention appeared clearly superior. Further research is required to evaluate the relative cost-effectiveness of the various medication safety interventions to facilitate decisions regarding uptake and implementation into clinical practice.

Auditing documentation on delivery room management using video and physiological recordings

OBJECTIVE

Neonatal resuscitation is often retrospectively documented, which can lead to inaccuracy and incomplete recording of delivery room management. In this study, we assessed the accuracy and completeness of neonatal resuscitation documentation in our neonatal intensive care unit.

METHODS

Recordings of physiological parameters and video data were performed in the delivery room and used to deduct the clinical condition of the infant, the interventions done and their effect on the infant's condition. The data from the recordings were compared with the documentation on neonatal stabilisation in the medical records (paper or digital).

RESULTS

Recordings of 54 infants were compared with the documentation in their medical records. In 93% of the medical records delivery room management was documented. The clinical condition of the infant at birth was documented in 76% and 1 min Apgar scores in 98%. Respiratory support was correctly documented in 83%, heart rate in 37% and oxygen saturation in 13%. In 57% use of supplemental oxygen and its indication were correctly reported. Seven infants were intubated and this was correctly documented in 57%. Apgar scores were compared between the recordings and the medical records. At 1 min, 5 min and 10 min after birth the Apgar score, given by the researcher using the recordings, was similar to the scores in the medical records in 33%, 44% and 53%, respectively.

CONCLUSIONS

Accurate and complete documentation of neonatal resuscitation continues to be a challenge. Recordings of physiological parameters and video imaging can improve documentation by providing detailed information.

Interventions to reduce pediatric medication errors: a systematic review

BACKGROUND AND OBJECTIVE

Medication errors cause appreciable morbidity and mortality in children. The objective was to determine the effectiveness of interventions to reduce pediatric medication errors, identify gaps in the literature, and perform meta-analyses on comparable studies.

METHODS

Relevant studies were identified from searches of PubMed, Embase, Scopus, Web of Science, the Cochrane Library, and the Cumulative Index to Nursing Allied Health Literature and previous systematic reviews. Inclusion criteria were peer-reviewed original data in any language testing an intervention to reduce medication errors in children. Abstract and full-text article review were conducted by 2 independent authors with sequential data extraction.

RESULTS

A total of 274 full-text articles were reviewed and 63 were included. Only 1% of studies were conducted at community hospitals, 11% were conducted in ambulatory populations, 10% reported preventable adverse drug events, 10% examined administering errors, 3% examined dispensing errors, and none reported cost-effectiveness data, suggesting persistent research gaps. Variation existed in the methods, definitions, outcomes, and rate denominators for all studies; and many showed an appreciable risk of bias. Although 26 studies (41%) involved computerized provider order entry, a meta-analysis was not performed because of methodologic heterogeneity. Studies of computerized provider order entry with clinical decision support compared with studies without clinical decision support reported a 36% to 87% reduction in prescribing errors; studies of preprinted order sheets revealed a 27% to 82% reduction in prescribing errors.

CONCLUSIONS

Pediatric medication errors can be reduced, although our understanding of optimal interventions remains hampered. Research should focus on understudied areas, use standardized definitions and outcomes, and evaluate cost-effectiveness.

Reducing the risk of harm from medication errors in children

MEDICATION ERRORS AFFECT THE PEDIATRIC AGE GROUP IN ALL SETTINGS

outpatient, inpatient, emergency department, and at home. Children may be at special risk due to size and physiologic variability, limited communication ability, and treatment by nonpediatric health care providers. Those with chronic illnesses and on multiple medications may be at higher risk of experiencing adverse drug events. Some strategies that have been employed to reduce harm from pediatric medication errors include e-prescribing and computerized provider order entry with decision support, medication reconciliation, barcode systems, clinical pharmacists in medical settings, medical staff training, package changes to reduce look-alike/sound-alike confusion, standardization of labeling and measurement devices for home administration, and quality improvement interventions to promote nonpunitive reporting of medication errors coupled with changes in systems and cultures. Future research is needed to measure the effectiveness of these preventive strategies.

Medication errors in the management of anaphylaxis in a pediatric emergency department

BACKGROUND

Despite the publication of recent guidelines for anaphylaxis management, many studies show that physicians are still not at ease with the management of anaphylaxis.

OBJECTIVES

To evaluate the rate and severity of medication errors before and after implementation of a standard order form for anaphylaxis management.

METHODS

A before-and-after study was conducted. All children <18 years of age presenting to a tertiary care pediatric hospital Emergency Department with anaphylaxis between September 2007 and November 2010 were included. Patients were divided into two groups according to intervention (Pre and Post). Intervention consisted of the implementation of a standard order form (SOF) for anaphylaxis management. The post-intervention group was further sub-divided into SOF+ (when the SOF was used) and SOF- (when the SOF was not used).

RESULTS

A total of 96 medical charts were reviewed. There were 31 patients in Pre and 65 in Post (29 in SOF+ and 36 in SOF-). A total of 243 drugs were ordered. Thirty-five percent (85/243) of these orders contained at least one medication error. Fifty-five percent (47/85) were dosage errors. The rate of medication errors was the same between Pre and Post (60% vs. 59%, p = 0.95). However, the rate of dosage errors was significantly reduced when the SOF was used (21% in SOF+ vs. 50% in Pre, p = 0.02 and 21% in SOF+ vs. 50% in SOF-, p = 0.02).

CONCLUSIONS

Medication errors in the management of anaphylaxis were frequent. Use of an SOF significantly reduced the rate of dosage errors.

Medication errors in pediatric emergencies: a systematic analysis

BACKGROUND

Errors in drug administration are among the commonest medical errors. Children are particularly at risk for such errors because of the need to calculate doses individually. Doses that are ten times the correct amount (1000% of the correct dose) are occasionally given and can be life-threatening. In a simulated resuscitation in a pediatric emergency room, an error of this type occurred for one of the 32 medications that were ordered. The highest error rates are to be expected in prehospital emergency medicine. In this review, we analyze the process of ordering medications and describe the potential interventions for lowering error rates that have been evaluated to date.

METHOD

Systematic literature review

RESULTS

We found 32 original publications that concerned the evaluation of interventions for lowering error rates in the ordering of medications for children. Error rates can be lowered by interventions that improve prescribers' knowledge of pediatric pharmacotherapy (courses, immediately accessible sources of information) and by aids to the cognitive process of ordering medication (calculators, computer programs, tables of doses by weight). They can also be lowered by raising awareness of the problem of erroneous medication ordering and by monitoring medication orders, as well as by structured communication and standardized, unambiguously labeled drug preparations. In the hospital setting, computer programs for medication orders with a built-in pediatric pharmacological database are highly recommended. In the prehospital setting, the "pediatric emergency ruler" enables accurate estimation of the patient's weight, provides age-appropriate dosage recommendations, and directly indicates the steps needed for calculation of the correct dose.

CONCLUSION

Children in medical emergency situations are at significant risk for medication errors. The measures described here can markedly lower the rate of dangerous errors.

Enhancing participant safety through electronically generated medication order sets in a clinical research environment: a medical informatics initiative

While clinical medicine is often well supported by health system information technology infrastructure, clinical research may need to create strategies to use clinical-medicine informational technology tools. The authors describe a medication-safety initiative that was carried out in a National Institutes of Health Clinical and Translational Science Award (CTSA)-sponsored clinical research environment. A web based, medical informatics application was designed and implemented that allowed research groups to build protocol specific, electronic medication templates that were subsequently used to create participant-specific medication order sets for conductance of clinical research activities in the CTSA-sponsored clinical research environment. The medical informatics initiative eliminated typewritten or handwritten medication orders, created research protocol-specific templates meeting institutional order-writing requirements, and formalized a rigorous review and approval process. Enhancing safety in medication ordering and prescribing practices in a clinical research environment provided the background for multidisciplinary cooperation in medical informatics.