The Impact of Technology on Prescribing Errors in Pediatric Intensive Care: A Before and After Study

Examining safety and efficacy of a fixed concentration heparin dosing strategy for anticoagulation in neonatal extracorporeal membrane oxygenation

OBJECTIVES

The paediatric intensive care unit changed heparin infusion dosing from a variable weight-based concentration to a fixed concentration strategy, when smart pump-based drug library was introduced. This change meant significantly lower rates of infusion were needed for the same dose of heparin in the neonatal population. We performed a safety and efficacy assessment of this change.

METHODS

We performed a retrospective single-centre evaluation based on data from respiratory VA-extracorporeal membrane oxygenation (ECMO) patients weighing ≤5 kg, pre and post the change to fixed strength heparin infusion. Efficacy was analysed by distribution of activated clotting times (ACT) and heparin dose requirements between the groups. Safety was analysed using thrombotic and haemorrhagic event rates. Continuous variables were reported as median, interquartile ranges, and non-parametric tests were used. Generalised estimating equations (GEE) were used to analyse associations of heparin dosing strategy with ACT and heparin dose requirements in the first 24 h of ECMO. Incidence rate ratios of circuit related thrombotic and haemorrhagic events between groups were analysed using Poisson regression with offset for run hours.

RESULTS

33 infants (20 variable weight-based, 13 fixed concentration) were analysed. Distribution of ACT ranges and heparin dose requirements were similar between the two groups during the ECMO run and this was confirmed by GEE. Incidence rate ratios of thrombotic (fixed v weight-based) (1.9 [0.5-8], p = .37), and haemorrhagic events (0.9 [0.1-4.9], p = .95) did not show statistically significant differences.

CONCLUSIONS

Fixed concentration dosing of heparin was at least equally effective and safe compared to a weight-based dosing.

Physicians' Perspectives with the E-prescribing System in Five Teaching Hospitals

OBJECTIVES

 Despite the evidence suggesting the potential of electronic prescribing (e-prescribing), this system also faces challenges that can lead to inefficiency and even failure. This study aimed to evaluate physicians' perspectives on the efficiency, effectiveness, opportunities, and challenges associated with the e-prescribing system.

METHODS

 In 2023, a descriptive analytics cross-sectional study was carried out. Due to the finite population size, all the physicians from five studied hospitals who agreed to participate in the study were included through the census method (n = 195). Data collection was conducted using a validated questionnaire. Data were analyzed using descriptive (mean, standard deviation, and frequency) and analytical (Pearson's correlation coefficient, two-sample t-test, one-way analysis of variance (ANOVA), and linear multiple regression model) statistics.

RESULTS

 The mean scores of efficiency and effectiveness were 47.47 ± 14.46 and 36.09 ± 10.67 out of 95 and 65, respectively. Removing the illegibility of the prescriptions (n = 22) was the most frequent opportunity and internet connectivity problem (n = 37) was the most frequent challenge associated with the e-prescribing system. There was a strong positive significant correlation between efficiency and effectiveness (r = 0.850, p < 0.01). Moreover, age was found to have a significant negative correlation with efficiency (B =  -7.261, p = 0.004) and effectiveness (B = - 5.784, p = 0.002).

CONCLUSION

 Physicians believe that e-prescribing enhances the efficiency and effectiveness of their work. There are many opportunity and challenges to the use of e-prescription. Assessing the needs of physicians, actively participating and training them in the stages of design and implementation, and conducting regular evaluations of the e-prescribing system are crucial to overcome the challenges. Our finding offers insightful information about how doctors see the e-prescribing system at teaching hospitals and provide a basis for managers and policy makers at the local and national levels to support the implementation of this system and plan for improvement of its shortcomings.

Implementation of a national system for best practice delivery of paediatric infusions

BACKGROUND

Standard concentration infusions and 'smart-pumps' are recognised as best practice in the paediatric setting. Implementation rates in European hospitals remain low. Children's Health Ireland (CHI) developed a paediatric 'smart-pump' drug library using standardised concentrations. At time of development, other Irish hospitals continued to use traditional pumps and weight-based paediatric infusions.

AIM

To expand best paediatric infusion practices by nationalising use of the CHI drug library.

SETTING

Tertiary paediatric, maternity and general acute hospitals, and associated transport services in Ireland.

DEVELOPMENT

The CHI drug library was first developed for paediatric intensive care and then adapted over a 10-year period for use in emergency departments, general paediatric wards, neonatal units, adult intensive care and transport services. The original library (42 drug lines, 1 'care-unit') was substantially expanded (223 drug lines, 6 'care-units'). A neonatal sub-library was created.

IMPLEMENTATION

Executive support, dedicated resources and governance structures were secured. Implementation and training packages were developed. Implementation has occurred across CHI, in paediatric and neonatal transport services, 58% (n = 11) of neonatal units, and 23% (n = 6) of paediatric sites.

EVALUATION

A before and after study demonstrated significant reductions in infusion prescribing errors (29.0% versus 8.4%, p < 0.001). Direct observation of infusions (n = 1023) found high compliance rates (98.9%) and low programming errors (1.6%). 100% of nurses (n = 132) surveyed 9 months after general ward implementation considered the drug library had enhanced patient safety.

CONCLUSION

Strategic planning and collaboration can standardise infusion practices. The CHI drug library has been approved as a National Standard of Care, with implementation continuing.

Mapping Injection Order Messages to Health Level 7 Fast Healthcare Interoperability Resources to Collate Infusion Pump Data

BACKGROUND

When administering an infusion to a patient, it is necessary to verify that the infusion pump settings are in accordance with the injection orders provided by the physician. However, the infusion rate entered into the infusion pump by the health care provider cannot be automatically reconciled with the injection order information entered into the electronic medical records (EMRs). This is because of the difficulty in linking the infusion rate entered into the infusion pump by the health care provider with the injection order information entered into the EMRs.

OBJECTIVES

This study investigated a data linkage method for reconciling infusion pump settings with injection orders in the EMRs.

METHODS

We devised and implemented a mechanism to convert injection order information into the Health Level 7 Fast Healthcare Interoperability Resources (FHIR), a new health information exchange standard, and match it with an infusion pump management system in a standard and simple manner using a REpresentational State Transfer (REST) application programming interface (API). The injection order information was extracted from Standardized Structured Medical Record Information Exchange version 2 International Organization for Standardization/technical specification 24289:2021 and was converted to the FHIR format using a commercially supplied FHIR conversion module and our own mapping definition. Data were also sent to the infusion pump management system using the REST Web API.

RESULTS

Information necessary for injection implementation in hospital wards can be transferred to FHIR and linked. The infusion pump management system application screen allowed the confirmation that the two pieces of information matched, and it displayed an error message if they did not.

CONCLUSION

Using FHIR, the data linkage between EMRs and infusion pump management systems can be smoothly implemented. We plan to develop a new mechanism that contributes to medical safety through the actual implementation and verification of this matching system.

Digital technology in medical visits: a critical review of its impact on doctor-patient communication

With the rapid advances of digital technology, computer-mediated medical practices are becoming increasingly dominant in medical visits. However, the question of how to ensure effective, patient-centered communication in this transition remains crucial. In this mini-review, we explore this topic by reviewing quantitative and survey-based studies, as well as discursive-interactional studies that focus on the visit as a communicative event. The review is organized into four sections: the introductory section provides a brief synthesis of the two main models used in medical practice and describes the effects of patient-centered communication practices on patients' health and well-being. The second section presents and discusses qualitative and quantitative studies that assess the effect of technology on medical interaction and its impact on patient-centered communication. The third section focuses on whether and how the digital medical record represents a "potential communication risk" during doctor-patient interactions and explores how certain pen-and-paper literacy practices could help mitigate these challenges. In the concluding section, we outline and analyze three key considerations for utilizing technologies to foster and enhance patient-centered communication during medical visits.

Short- and long-term effects of an electronic medication management system on paediatric prescribing errors

Electronic medication management (eMM) systems are designed to improve safety, but there is little evidence of their effectiveness in paediatrics. This study assesses the short-term (first 70 days of eMM use) and long-term (one-year) effectiveness of an eMM system to reduce prescribing errors, and their potential and actual harm. We use a stepped-wedge cluster randomised controlled trial (SWCRCT) at a paediatric referral hospital, with eight clusters randomised for eMM implementation. We assess long-term effects from an additional random sample of medication orders one-year post-eMM. In the SWCRCT, errors that are potential adverse drug events (ADEs) are assessed for actual harm. The study comprises 35,260 medication orders for 4821 patients. Results show no significant change in overall prescribing error rates in the first 70 days of eMM use (incident rate ratio [IRR] 1.05 [95%CI 0.92-1.21], but a 62% increase (IRR 1.62 [95%CI 1.28-2.04]) in potential ADEs suggesting immediate risks to safety. One-year post-eMM, errors decline by 36% (IRR 0.64 [95%CI 0.56-0.72]) and high-risk medication errors decrease by 33% (IRR 0.67 [95%CI 0.51-0.88]) compared to pre-eMM. In all periods, dose error rates are more than double that of other error types. Few errors are associated with actual harm, but 71% [95%CI 50-86%] of patients with harm experienced a dose error. In the short-term, eMM implementation shows no improvement in error rates, and an increase in some errors. A year after eMM error rates significantly decline suggesting long-term benefits. eMM optimisation should focus on reducing dose errors due to their high frequency and capacity to cause harm.

Duplicate Medication Order Errors: Safety Gaps and Recommendations for Improvement

Background: Duplicate medication orders are a prominent type of medication error that in some circumstances has increased after implementation of health information technology. Duplicate medication orders are commonly defined as two or more active orders for the same medication or medications within the same therapeutic class. While there have been several studies that have identified contributing factors and described potential solutions, duplicate medication order errors continue to impact patient safety. Methods: We analyzed 377 reports from 95 healthcare facilities to more granularly define the types of duplicate medication order errors and the context under which these errors occurred, as well as potential contributing factors. Results: Of the 377 reports reviewed, 304 (80.6%) met the criteria to be defined as a duplicate medication order error. The most frequent duplicate medication order error type was same order (n=131, 43.1%), followed by same therapeutic class (n=98, 32.2%) and same medication (n=70, 23.0%). Errors were identified during different medication process tasks and most commonly during medication reconciliation during the patient’s stay in the hospital (n=72, 23.7%) and during pharmacy verification (n=36, 11.8%). Factors contributing to these errors included health information technology issues (n=63, 20.7%), gaps in care coordination (n=44, 14.5%), and a prior dose or medication order not being discontinued (n=52, 17.1%). Conclusion: Our results highlight specific areas for practice improvement, and we make recommendations for how healthcare facilities can better address duplicate medication order errors.

Developing Strategic Recommendations for Implementing Smart Pumps in Advanced Healthcare Systems to Improve Intravenous Medication Safety

Avoidable harm associated with medication is a persistent problem in health systems and the use of preprogrammed infusion devices ('smart pumps') and data monitoring is seen as a core approach to mitigating and reducing the incidence of these harms. However, smart pumps are costly to procure, configure and maintain (in both human and financial terms) and are often poorly implemented. Variation in the manner in which medicines are prepared and used within complex modern healthcare systems exacerbates these challenges, and a strategic human-centred approach is needed to support their implementation. A symposium of 36 clinical and academic medication safety experts met virtually to discuss the current 'state of the art' and to propose strategic recommendations to support the implementation of medication administration technology to improve medication safety. The recommendations were that health systems (1) standardise infusion concentrations to facilitate the development of ready-to-administer formulations of frequently used medicines, and support 'out of the box' programming of infusion devices; (2) develop and implement drug libraries using human-centred approaches and the aforementioned standard concentrations, with a theoretical understanding of how devices are used in practice; (3) develop standardised metrics and outcomes to support the interpretation of data produced by infusion devices; (4) involve all stakeholders in the development of drug libraries and metrics to ensure broad understanding of the devices, their benefits and limitations; and (5) leverage input into device design, working with manufacturers and users. Using this strategic approach, it is then possible to envisage and plan real-world implementation studies using a uniform approach to quantify improvements in safety, efficiency and cost effectiveness.

Quantifying the Impact of Infusion Alerts and Alarms on Nursing Workflows: A Retrospective Analysis

BACKGROUND

Smart infusion pumps affect workflows as they add alerts and alarms in an information-rich clinical environment where alarm fatigue is already a major concern. An analytic approach is needed to quantify the impact of these alerts and alarms on nursing workflows and patient safety.

OBJECTIVES

To analyze a detailed infusion dataset from a smart infusion pump system and identify contributing factors for infusion programming alerts, operational alarms, and alarm resolution times.

METHODS

We analyzed detailed infusion pump data across four hospitals in a health system for up to 1 year. The prevalence of alerts and alarms was grouped by infusion type and a selected list of 32 high-alert medications (HAMs). Logistic regression was used to explore the relationship between a set of risk factors and the occurrence of alerts and alarms. We used nonparametric tests to explore the relationship between alarm resolution times and a subset of predictor variables.

RESULTS

The study dataset included 745,641 unique infusions with a total of 3,231,300 infusion events. Overall, 28.7% of all unique infusions had at least one operational alarm, and 2.1% of all unique infusions had at least one programming alert. Alarms averaged two per infusion, whereas at least one alert happened in every 48 unique infusions. Eight percent of alarms took over 4 minutes to resolve. Intravenous fluid infusions had the highest rate of error-state occurrence. HAMs had 1.64 more odds for alerts than the rest of the infusions. On average, HAMs had a higher alert rate than maintenance fluids.

CONCLUSION

Infusion pump alerts and alarms impact clinical care, as alerts and alarms by design interrupt clinical workflow. Our study showcases how hospital system leadership teams can leverage infusion pump informatics to prioritize quality improvement and patient safety initiatives pertaining to infusion practices.

Development and Evaluation of an Intravenous Infusion Sequence Annotation System

OBJECTIVES

The sequence of intravenous infusions may impact the efficacy, safety, and cost of intravenous medications. The study describes and assesses a computerized clinical decision support annotation system capable of analyzing the sequence of intravenous infusions.

METHODS

All intravenous medications on the hospital formulary were analyzed based on factors that impact intravenous infusion sequence. Eight pharmacy infusion knowledge databases were constructed based on Hospital Infusion Standards. These databases were incorporated into the computerized sequence annotation module within the electronic health record system. The annotation process was changed from pharmacists' manual annotation (phase 1) to computer-aided pharmacist manual annotation (phase 2) to automated computer annotation (phase 3).

RESULTS

Comparing phase 2 to phase 1, there were significant differences in sequence annotation with regards to the percentage of hospital wards annotated (100% vs. 4.65%, chi-square  = 180.95, p < 0.001), percentage of patients annotated (64.18% vs. 0.52%, chi-square = 90.46, p < 0.001), percentage of intravenous orders annotated (75.67% vs. 0.77%, chi-square = 118.78, p < 0.001), and the number of tubing flushes per ward per day (118.51 vs. 2,115.00, p < 0.001). Compared with phase 1, there were significant cost savings in tubing flushes in phase 2 and phase 3. Compared with phase 1, there was significant difference in the time nurses spent on tubing flushes in phase 2 and phase 3 (1,244.94 vs. 21,684.8 minutes, p < 0.001; 1,369.51 vs. 21,684.8 minutes, p < 0.001). Compared with phase 1, significantly less time was required for pharmacist annotation in phase 2 and phase 3 (90.6 vs. 4,753.57 minutes, p < 0.001; 0.05 vs. 4,753.57 minutes, p < 0.001).

CONCLUSION

A computerized infusion annotation system is efficient in sequence annotation and significant savings in tubing flushes can be achieved as a result.

The impact of health information technology on prescribing errors in hospitals: a systematic review and behaviour change technique analysis

BACKGROUND

Health information technology (HIT) is known to reduce prescribing errors but may also cause new types of technology-generated errors (TGE) related to data entry, duplicate prescribing, and prescriber alert fatigue. It is unclear which component behaviour change techniques (BCTs) contribute to the effectiveness of prescribing HIT implementations and optimisation. This study aimed to (i) quantitatively assess the HIT that reduces prescribing errors in hospitals and (ii) identify the BCTs associated with effective interventions.

METHODS

Articles were identified using CINAHL, EMBASE, MEDLINE, and Web of Science to May 2020. Eligible studies compared prescribing HIT with paper-order entry and examined prescribing error rates. Studies were excluded if prescribing error rates could not be extracted, if HIT use was non-compulsory or designed for one class of medication. The Newcastle-Ottawa scale was used to assess study quality. The review was reported in accordance with the PRISMA and SWiM guidelines. Odds ratios (OR) with 95% confidence intervals (CI) were calculated across the studies. Descriptive statistics were used to summarise effect estimates. Two researchers examined studies for BCTs using a validated taxonomy. Effectiveness ratios (ER) were used to determine the potential impact of individual BCTs.

RESULTS

Thirty-five studies of variable risk of bias and limited intervention reporting were included. TGE were identified in 31 studies. Compared with paper-order entry, prescribing HIT of varying sophistication was associated with decreased rates of prescribing errors (median OR 0.24, IQR 0.03-0.57). Ten BCTs were present in at least two successful interventions and may be effective components of prescribing HIT implementation and optimisation including prescriber involvement in system design, clinical colleagues as trainers, modification of HIT in response to feedback, direct observation of prescriber workflow, monitoring of electronic orders to detect errors, and system alerts that prompt the prescriber.

CONCLUSIONS

Prescribing HIT is associated with a reduction in prescribing errors in a variety of hospital settings. Poor reporting of intervention delivery and content limited the BCT analysis. More detailed reporting may have identified additional effective intervention components. Effective BCTs may be considered in the design and development of prescribing HIT and in the reporting and evaluation of future studies in this area.

A modified Delphi to define drug dosing errors in pediatric critical care

Background

There is no globally accepted definition for dosing error in adult or pediatric practice. The definition of pediatric dosing error varies greatly in the literature. The objective of this study was to develop a framework, informed by a set of principles, for a clinician-based definition of drug dosing errors in critically ill children, and to identify the range that practitioners agree is a dosing error for different drug classes and clinical scenarios.

Methods

We conducted a nationwide three staged modified Delphi from May to December 2019. Expert clinicians included Canadian pediatric intensive care unit (PICU) physicians, pharmacists and nurses, with a least 5 years’ experience. Outcomes were underlying principles of drug dosing, and error thresholds, as defined by proportion above and below reference range, for common PICU medications and clinical scenarios.

Results

Forty-four participants met eligibility, and response rates were 95, 86 and 84% for all three rounds respectively. Consensus was achieved for 13 of 15 principles, and 23 of 30 error thresholds. An over-dosed drug that is intercepted, an under-dose of a possibly life-saving medication, dosing 50% above or below target range and not adjusting for a drug interaction were agreed principles of dosing error. Altough there remained much uncertainty in defining dosing error, expert clinicians agreed that, for most medication categories and clinical scenarios, dosing over or below 10% of reference range was considered an error threshold.

Conclusion

Dosing principles and threshold are complex in pediatric critical care, and expert clinicians were uncertain about whether many scenarios were considered in error. For most intermittent medications, dosing over 10% below or above reference range was considered a dosing error, although this was largely influenced by clinical context and drug properties. This consensus driven error threshold will help guide routine clinical dosing practice, standardized reporting and drug quality improvement in pediatric critical care.

Direct Observational Study of Interfaced Smart-Pumps in Pediatric Intensive Care

BACKGROUND

Processes for delivery of high-risk infusions in pediatric intensive care units (PICUs) are complex. Standard concentration infusions (SCIs), smart-pumps, and electronic prescribing are recommended medication error reduction strategies. Implementation rates in Europe lag behind those in the United States. Since 2012, the PICU of an Irish tertiary pediatric hospital has been using a smart-pump SCI library, interfaced with electronic infusion orders (Philips ICCA). The incidence of infusion errors is unknown.

OBJECTIVES

To determine the frequency, severity, and distribution of smart-pump infusion errors in PICUs.

METHODS

Programmed infusions were directly observed at the bedside. Parameters were compared against medication orders and autodocumented infusion data. Identified deviations were categorized as medication errors or discrepancies. Error rates (%) were calculated as infusions with errors and errors per opportunities for error (OEs). Predefined definitions, multidisciplinary consensus and grading processes were employed.

RESULTS

A total of 1,023 infusions for 175 patients were directly observed over 27 days between February and September 2017. The drug library accommodated 96.5% of infusions. Compliance with the drug library was 98.9%. A total of 133 infusions had ≥1 error (13.0%); a further 58 (5.7%) had ≥1 discrepancy. From a total of 4,997 OEs, 153 errors (3.1%) and 107 discrepancies (2.1%) were observed. Undocumented bolus doses were most commonly identified (n = 81); this was the only deviation in 36.1% (n = 69) of infusions. Programming errors were rare (0.32% OE). Errors were minor, with just one requiring minimal intervention to prevent harm.

CONCLUSION

The error rates identified are low compared with similar studies, highlighting the benefits of smart-pumps and autodocumented infusion data in PICUs. A range of quality improvement opportunities has been identified.