Impact of electronic chemotherapy order forms on prescribing errors at an urban medical center: results from an interrupted time-series analysis

Evaluation of clinical decision support systems in oncology: An updated systematic review

With increasing reliance on technology in oncology, the impact of digital clinical decision support (CDS) tools needs to be examined. A systematic review update was conducted and peer-reviewed literature from 2016 to 2022 were included if CDS tools were used for live decision making and comparatively assessed quantitative outcomes. 3369 studies were screened and 19 were included in this updated review. Combined with a previous review of 24 studies, a total of 43 studies were analyzed. Improvements in outcomes were observed in 42 studies, and 34 of these were of statistical significance. Computerized physician order entry and clinical practice guideline systems comprise the greatest number of evaluated CDS tools (13 and 10 respectively), followed by those that utilize patient-reported outcomes (8), clinical pathway systems (8) and prescriber alerts for best-practice advisories (4). Our review indicates that CDS can improve guideline adherence, patient-centered care, and care delivery processes in oncology.

Computer programs used in the field of hospital pharmacy for the management of dangerous drugs: systematic review of literature

Background

This review wants to highlight the importance of computer programs used to control the steps in the management of dangerous drugs. It must be taken into account that there are phases in the process of handling dangerous medicines in pharmacy services that pose a risk to the healthcare personnel who handle them. Objective: To review the scientific literature to determine what computer programs have been used in the field of hospital pharmacy for the management of dangerous drugs (HDs).

Methods

The following electronic databases were searched from inception to July 30, 2021: MEDLINE (via PubMed), Embase, Cochrane Library, Scopus, Web of Science, Latin American and Caribbean Literature in Health Sciences (LILACS) and Medicine in Spanish (MEDES). The following terms were used in the search strategy: "Antineoplastic Agents," "Cytostatic Agents," "Hazardous Substances," "Medical Informatics Applications," "Mobile Applications," "Software," "Software Design," and "Pharmacy Service, Hospital."

Results

A total of 104 studies were retrieved form the databases, and 18 additional studies were obtained by manually searching the reference lists of the included studies and by consulting experts. Once the inclusion and exclusion criteria were applied, 26 studies were ultimately included in this review. Most of the applications described in the included studies were used for the management of antineoplastic drugs. The most commonly controlled stage was electronic prescription; 18 studies and 7 interventions carried out in the preparation stage focused on evaluating the accuracy of chemotherapy preparations.

Conclusion

Antineoplastic electronic prescription software was the most widely implemented software at the hospital level. No software was found to control the entire HD process. Only one of the selected studies measured safety events in workers who handle HDs. Moreover, health personnel were found to be satisfied with the implementation of this type of technology for daily work with these medications. All studies reviewed herein considered patient safety as their final objective. However, none of the studies evaluated the risk of HD exposure among workers.

VicTAG chemotherapy audit toolkit: Improving chemotherapy quality and safety

OBJECTIVE

Off-protocol prescribing of systemic anti-cancer therapy (SACT) can lead to concerns about effectiveness of patient care. To identify variations in practice, a toolkit was developed for health services to address patient safety and the risk of sub-optimal outcomes for patients.

DATA SOURCES

Following significant incidents with SACT in South Australia and New South Wales, the Department of Health and Human Services, Victoria (the department) conducted an assessment of Victorian public health services to understand current practice regarding SACT protocol governance. A literature review examining SACT auditing was also undertaken to guide improvements. A department supported Chemotherapy Audit Toolkit (CAT) was created for implementation at public hospitals in Victoria. A post-implementation survey was done on uptake and issue identification.

DATA SUMMARY

An initial assessment showed that 27% of Victorian public health services were undertaking retrospective review of SACT dosing, which was targeted for improvement. The literature review identified little guidance, however an audit of current sector practices found several audit methodologies. A process that involved audits by health services assessing their own practice was adopted. The toolkit was developed and piloted with health services. A post-implementation survey showed that 20% of services were using the toolkit, 35% were implementing the toolkit and 45% did not use the toolkit.

CONCLUSIONS

The VicTAG CAT has been adopted by more than half of Victorian public health services and is being used to influence prescribing. Implementation of the toolkit has been affected by resource reallocation due to the COVID-19 pandemic. The CAT is available online.

In-Hospital Prescription Checking System for Hospitalized Patients with Decreased Glomerular Filtration Rate

Background

Clinical decision support systems (CDSS) are reported to be useful in preventing dosage errors in renally excreted drugs by alerting hospital pharmacists to inadequate dosages for hospitalized patients with decreased GFR. However, it is unclear whether CDSS can reduce dosage errors in renally excreted drugs in hospitalized patients. To prevent dosage errors in renally excreted drugs, we introduced a prescription checking system (PCS) for in-hospital prescriptions. This retrospective study aimed to evaluate whether a prescription audit by hospital pharmacists using the PCS reduced the rate of dosage errors in renally excreted drugs.

Methods

The target drugs were allopurinol, cibenzoline, famotidine, and pilsicainide. Interrupted time series analysis was used to evaluate trends in the 4-weekly dosage error rates over 52 weeks before PCS implementation and 52 weeks after PCS implementation.

Results

Before and after PCS implementation, 474 and 331 prescriptions containing one of the targeted drugs, respectively, were generated. The estimated baseline level of the 4-weekly dosage error rates was 34%. The trend before the PCS implementation was stable with no observable trend. The estimated level change from the last point in the pre-PCS implementation to the first point in the PCS implementation was -20% (P<0.001). There was no change in the trend after PCS implementation.

Conclusions

We demonstrated that a prescription audit by hospital pharmacists using the PCS reduced the rate of dosage errors in the target renally excreted drugs in hospitalized patients. Although further studies are needed to confirm whether our results can be generalized to other health facilities, our findings highlight the need for a PCS to prevent the overdose of renally excreted drugs.

The efficiency-thoroughness trade-off after implementation of electronic medication management: a qualitative study in paediatric oncology

OBJECTIVE

The efficiency-thoroughness trade-off (ETTO) principle proposes that people and organizations are often required to make a trade-off between being efficient and being thorough, as it is difficult to be both efficient and thorough at the same time. This study aimed to compare pre- electronic medication management system (EMMS) expectation of how an EMMS is likely to impact on efficiency and thoroughness to post-EMM experiences of an EMMS and the ETTO.

DESIGN

Qualitative interview study.

SETTING

A paediatric oncology cancer centre in a large paediatric tertiary teaching hospital in Sydney, Australia.

PARTICIPANTS

Forty-four semi-structured interviews with doctors, nurses and pharmacists six months prior to and two years following implementation of an EMMS.

RESULTS

Prior to EMM implementation, staff identified a number of areas of work where both efficiency and thoroughness were expected to improve with EMM. These included ease of accessibility of the medication record, and organization and legibility of medication information. Following EMMS implementation, staff reported improvements in these areas. However, the EMMS was perceived to drive thoroughness (safety) benefits at the expense of efficiency (time). Measures to improve safety in the EMMS enforced processes that required time, such as medication double-checking procedures.

CONCLUSIONS

Overall, staff were aware of the competitive interplay between thoroughness and efficiency and reported that introduction of an EMMS had imposed processes that favoured improvements in thoroughness at the expense of efficiency.

How effective are electronic medication systems in reducing medication error rates and associated harm among hospital inpatients? A systematic review and meta-analysis

OBJECTIVE

To conduct a systematic review and meta-analysis to assess: 1) changes in medication error rates and associated patient harm following electronic medication system (EMS) implementation; and 2) evidence of system-related medication errors facilitated by the use of an EMS.

MATERIALS AND METHODS

We searched Medline, Scopus, Embase, and CINAHL for studies published between January 2005 and March 2019, comparing medication errors rates with or without assessments of related harm (actual or potential) before and after EMS implementation. EMS was defined as a computer-based system enabling the prescribing, supply, and/or administration of medicines. Study quality was assessed.

RESULTS

There was substantial heterogeneity in outcomes of the 18 included studies. Only 2 were strong quality. Meta-analysis of 5 studies reporting change in actual harm post-EMS showed no reduced risk (RR: 1.22, 95% CI: 0.18-8.38, P = .8) and meta-analysis of 3 studies reporting change in administration errors found a significant reduction in error rates (RR: 0.77, 95% CI: 0.72-0.83, P = .004). Of 10 studies of prescribing error rates, 9 reported a reduction but variable denominators precluded meta-analysis. Twelve studies provided specific examples of system-related medication errors; 5 quantified their occurrence.

DISCUSSION AND CONCLUSION

Despite the wide-scale adoption of EMS in hospitals around the world, the quality of evidence about their effectiveness in medication error and associated harm reduction is variable. Some confidence can be placed in the ability of systems to reduce prescribing error rates. However, much is still unknown about mechanisms which may be most effective in improving medication safety and design features which facilitate new error risks.

Impact of computerised physician order entry (CPOE) on the incidence of chemotherapy-related medication errors: a systematic review

Purpose

Computerised prescriber (or physician) order entry (CPOE) implementation is one of the strategies to reduce medication errors. The extent to which CPOE influences the incidence of chemotherapy-related medication errors (CMEs) was not previously collated and systematically reviewed. Hence, this study was designed to collect, collate, and systematically review studies to evaluate the effect of CPOE on the incidence of CMEs.

Methods

A search was performed of four databases from 1 January 1995 until 1 August 2019. English-language studies evaluating the effect of CPOE on CMEs were selected as per inclusion and exclusion criteria. The total CMEs normalised to total prescriptions pre- and post-CPOE were extracted and collated to perform a meta-analysis using the ‘meta’ package in R. The systematic review was registered with PROSPERO CRD42018104220.

Results

The database search identified 1621 studies. After screening, 19 studies were selected for full-text review, of which 11 studies fulfilled the selection criteria. The meta-analysis of eight studies with a random effects model showed a risk ratio of 0.19 (95% confidence interval: 0.08–0.44) favouring CPOE (I² = 99%).

Conclusion

The studies have shown consistent reduction in CMEs after CPOE implementation, except one study that showed an increase in CMEs. The random effects model in the meta-analysis of eight studies showed that CPOE implementation reduced CMEs by 81%.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00228-021-03099-9.

Use of interrupted time series methods in the evaluation of health system quality improvement interventions: a methodological systematic review

BACKGROUND

When randomisation is not possible, interrupted time series (ITS) design has increasingly been advocated as a more robust design to evaluating health system quality improvement (QI) interventions given its ability to control for common biases in healthcare QI. However, there is a potential risk of producing misleading results when this rather robust design is not used appropriately. We performed a methodological systematic review of the literature to investigate the extent to which the use of ITS has followed best practice standards and recommendations in the evaluation of QI interventions.

METHODS

We searched multiple databases from inception to June 2018 to identify QI intervention studies that were evaluated using ITS. There was no restriction on date, language and participants. Data were synthesised narratively using appropriate descriptive statistics. The risk of bias for ITS studies was assessed using the Cochrane Effective Practice and Organisation of Care standard criteria. The systematic review protocol was registered in PROSPERO (registration number: CRD42018094427).

RESULTS

Of 4061 potential studies and 2028 unique records screened for inclusion, 120 eligible studies assessed eight QI strategies and were from 25 countries. Most studies were published since 2010 (86.7%), reported data using monthly interval (71.4%), used ITS without a control (81%) and modelled data using segmented regression (62.5%). Autocorrelation was considered in 55% of studies, seasonality in 20.8% and non-stationarity in 8.3%. Only 49.2% of studies specified the ITS impact model. The risk of bias was high or very high in 72.5% of included studies and did not change significantly over time.

CONCLUSIONS

The use of ITS in the evaluation of health system QI interventions has increased considerably over the past decade. However, variations in methodological considerations and reporting of ITS in QI remain a concern, warranting a need to develop and reinforce formal reporting guidelines to improve its application in the evaluation of health system QI interventions.

Electronic ordering and the management of treatment interdependencies: a qualitative study of paediatric chemotherapy

BACKGROUND

There are serious safety risks associated with chemotherapy, often associated with interdependencies in regimens administered over months or years. Various strategies are used to manage these risks. Computerized provider order entry (CPOE) systems are also implemented to improve medication safety. Little is known regarding the effect of CPOE on how clinicians manage chemotherapy interdependencies and their associated safety strategies.

METHODS

We conducted a multi-method qualitative study in a paediatric hospital. We analysed 827 oncology incidents reported following CPOE implementation and carried out semi-structured interviews with doctors (n = 10), nurses (n = 6), a pharmacist, and oncology CPOE team members (n = 2). Results were interpreted according to safety models (ultra-safe, high-reliability organisations [HROs], or ultra-adaptive).

RESULTS

Incident reports highlighted two interrelated types of interdependencies: those within organisation of clinical activities and those inherent in chemotherapy regimens. Clinicians reported strategies to address chemotherapy risks and interdependencies. These included rigid rules and 'no go' contexts for treatment to proceed, typical of the ultra-safe model; use of time (e.g. planning only so far ahead) and sensitivity to operations, typical of HROs. We identified three different time horizons in CPOE use in relation to patients' treatments: life-long, the whole regimen, and the 'here and now'. CPOE supported ultra-safe strategies through automation and access to rules/standardisation, but also created difficulties and contributed to incidents. It supported the 'here and now' better than a life-long or whole regimen view of a patient treatment. Sensitivity to operations was essential to anticipate and resolve uncertainties, hazards, CPOE limitations, and mismatches between CPOE processes and workflow in practice.

CONCLUSIONS

Within oncology, CPOE appears to move the 'mix' of risk strategies towards ultra-safe models of safety and protocol-mandated care. However, in order to operate ultra-safe strategies embedded in CPOE and stay on protocol it is essential for clinicians to be thoughtful and show sensitivity to operations in CPOE use. CPOE design can be advanced by better consideration of mechanisms to support interdependencies.

A Systematic Review of Clinical Decision Support Systems for Clinical Oncology Practice

BACKGROUND

Electronic health records are central to cancer care delivery. Electronic clinical decision support (CDS) systems can potentially improve cancer care quality and safety. However, little is known regarding the use of CDS systems in clinical oncology and their impact on patient outcomes.

METHODS

A systematic review of peer-reviewed studies was performed to evaluate clinically relevant outcomes related to the use of CDS tools for the diagnosis, treatment, and supportive care of patients with cancer. Peer-reviewed studies published from 1995 through 2016 were included if they assessed clinical outcomes, patient-reported outcomes (PROs), costs, or care delivery process measures.

RESULTS

Electronic database searches yielded 2,439 potentially eligible papers, with 24 studies included after final review. Most studies used an uncontrolled, pre-post intervention design. A total of 23 studies reported improvement in key study outcomes with use of oncology CDS systems, and 12 studies assessing the systems for computerized chemotherapy order entry demonstrated reductions in prescribing error rates, medication-related safety events, and workflow interruptions. The remaining studies examined oncology clinical pathways, guideline adherence, systems for collection and communication of PROs, and prescriber alerts.

CONCLUSIONS

There is a paucity of data evaluating clinically relevant outcomes of CDS system implementation in oncology care. Currently available data suggest that these systems can have a positive impact on the quality of cancer care delivery. However, there is a critical need to rigorously evaluate CDS systems in oncology to better understand how they can be implemented to improve patient outcomes.

Impact of infection control measures on the related costs and the amount of broad-spectrum antimicrobial agents used in a hospital: A time-series analysis

Health care-associated infections (HAIs) worsen patient prognoses and increase medical costs. Antimicrobial stewardship (AMS), which involves appropriate use of antimicrobial agents and antiseptics, may be beneficial for addressing the issue of HAIs. In hospitals, an infection control team (ICT) plays an important role on the appropriate use of antimicrobial agents and antiseptics based on AMS. We aimed to conduct a time-series analysis of the efficacies of infection control measures in terms of related costs, amount of broad-spectrum antimicrobial agents used (carbapenems and quinolones), and methicillin-resistant Staphylococcus aureus (MRSA) detection rates. This retrospective cross-sectional study included in-hospital patients treated at a single institute between January 2012 and December 2015. The intervention start point (initiation of infection control measures) was January 2014. All survey items were subjected to segmented regression analysis using an autoregressive integrated moving average (ARIMA) model. Differences between pre-intervention and postintervention levels and their trends were assessed, using a statistical significance cutoff of P < .05. The infection control costs demonstrated a significantly increasing trend, despite significant decreases in the amount of carbapenems used. Accordingly, the implementation of infection control measures was associated with increased costs, whereas carbapenem use decreased immediately after intervention. Postintervention levels, trends of quinolone use, or MRSA detection rates did not reveal significant changes. Although implementation of infection control measures induced gradual increases in related costs, these measures led to immediate reductions in carbapenem use. Our study findings will support the establishment of more effective and economical infection control measures.

Medication safety incidents in paediatric oncology after electronic medication management system implementation

Objective

To explore medication safety issues related to use of an electronic medication management system (EMM) in paediatric oncology practice, through the analysis of patient safety incident reports.

Methods

We analysed 827 voluntarily reported incidents relating to oncology patients that occurred over an 18‐month period immediately following implementation of an EMM in a paediatric hospital in Australia. We identified medication‐related and EMM‐related incidents and carried out a content analysis to identify patterns.

Results

We found ~79% (n = 651) of incidents were medication‐related and, of these, ~45% (n = 294) were EMM‐related. Medication‐related incidents included issues with: prescribing; dispensing; administration; patient transfers; missing chemotherapy protocols and information on current stage of patient treatment; coordination of chemotherapy administration; handling or storing medications; children or families handling medications. EMM‐related incidents were classified into four groups: technical issues, issues with the user experience, unanticipated problems in EMM workflow, and missing safety features.

Conclusions

Incidents reflected difficulties with managing therapies rich in interdependencies. EMM, and especially its ‘automaticity’, contributed to these incidents. As EMM impacts on safety in such high‐risk settings, it is essential that users are aware of and attend to EMM automatic behaviours and are equipped to troubleshoot them.

Measuring cause-and-effect relationships without randomized clinical trials: Quasi-experimental methods for gynecologic oncology research

Clinical research in gynecologic oncology has seen a proliferation of studies that investigate the effectiveness of treatments using existing data sources such as cancer registries, electronic health records, and insurance claims. These observational studies are often feasible when randomized trial may not be, and may be more generalizable than randomized trials, because of greater diversity in the study populations. While statistical methods such as multivariable regression, matching, stratification, and weighting can adjust for the confounding in observational studies, statistical adjustment cannot control for confounders that are unmeasured in the data. Observational studies comparing the effectiveness of treatments for gynecologic malignancies are susceptible to bias from unmeasured confounding because factors like functional status, frailty and disease burden, which influence treatment selection and outcome, are often not reported in existing data sources. Like randomized trials, quasi-experimental designs attempt to account for both measured and unmeasured confounding by exploiting natural experiments arising in the real world. These methods are underutilized in gynecologic oncology research and are particularly relevant to studies that use large datasets to study the effectiveness of treatments. In this review, we consider methodological challenges that arise in the analysis of non-randomized studies, and describe how application of quasi-experimental methodology can estimate unbiased treatment effects even in the presence of unmeasured confounders.

Transcription Errors of Blood Glucose Values and Insulin Errors in an Intensive Care Unit: Secondary Data Analysis Toward Electronic Medical Record-Glucometer Interoperability

BACKGROUND

Critically ill patients require constant point-of-care blood glucose testing to guide insulin-related decisions. Transcribing these values from glucometers into a paper log and the electronic medical record is very common yet error-prone in intensive care units, given the lack of connectivity between glucometers and the electronic medical record in many US hospitals.

OBJECTIVE

We examined (1) transcription errors of glucometer blood glucose values documented in the paper log and in the electronic medical record vital signs flow sheet in a surgical trauma intensive care unit, (2) insulin errors resulting from transcription errors, (3) lack of documenting these values in the paper log and the electronic medical record vital signs flow sheet, and (4) average time for docking the glucometer.

METHODS

This secondary data analysis examined 5049 point-of-care blood glucose tests. We obtained values of blood glucose tests from bidirectional interface software that transfers the meters' data to the electronic medical record, the paper log, and the vital signs flow sheet. We obtained patient demographic and clinical-related information from the electronic medical record.

RESULTS

Of the 5049 blood glucose tests, which were pertinent to 234 patients, the total numbers of undocumented or untranscribed tests were 608 (12.04%) in the paper log, 2064 (40.88%) in the flow sheet, and 239 (4.73%) in both. The numbers of transcription errors for the documented tests were 98 (2.21% of 4441 documented tests) in the paper log, 242 (8.11% of 2985 tests) in the flow sheet, and 43 (1.64% of 2616 tests) in both. The numbers of transcription errors per patient were 0.4 (98 errors/234 patients) in the paper log, 1 (242 errors/234 patients) in the flow sheet, and 0.2 in both (43 errors/234 patients). Transcription errors in the paper log, the flow sheet, and in both resulted in 8, 24, and 2 insulin errors, respectively. As a consequence, patients were given a lower or higher insulin dose than the dose they should have received had there been no errors. Discrepancies in insulin doses were 2 to 8 U lower doses in paper log transcription errors, 10 U lower to 3 U higher doses in flow sheet transcription errors, and 2 U lower in transcription errors in both. Overall, 30 unique insulin errors affected 25 of 234 patients (10.7%). The average time from point-of-care testing to meter docking was 8 hours (median 5.5 hours), with some taking 56 hours (2.3 days) to be uploaded.

CONCLUSIONS

Given the high dependence on glucometers for point-of-care blood glucose testing in intensive care units, full electronic medical record-glucometer interoperability is required for complete, accurate, and timely documentation of blood glucose values and elimination of transcription errors and the subsequent insulin-related errors in intensive care units.

Chemotherapy administration standards and guidelines: The development of a resource document

There are no nationally recognised guidelines for the handling and administration of chemotherapy in South Africa. The Independent Clinical Oncology Network’s Chemotherapy Administration Standards and Guidelines Resource Documentwas developed over 2 years and first introduced at a South African international oncology conference in 2017. A working group consisting of oncologists and oncology nurses was set up to address this deficiency. Pragmatic guidelines suitable to a wide range of local chemotherapy administration practices were developed using an iterative, multidisciplinary, collaborative process. The consensus was that these guidelines should be appropriate to the South African context. Safety, standard operational procedures, recommended professional competencies and training were central to the document. Guidelines for prescribing, storing, mixing, dispensing, administering and disposing of chemotherapy were included. Patient consent and involvement, patient and staff safety, recommended professional competencies, management of accidents and errors, error reporting and local legal requirements are dealt with in detail. The hope is that these guidelines will be used as a resource document for South African chemotherapy practices, both public and private. The document is supported by standard operating procedures and action steps. These were developed to promote the use of the guidelines and to support pragmatic quality assurance measures at practice level. These standards and guidelines will be regularly updated, based on needs identified and deficiencies noted.

Improving the Safety and Quality of Systemic Treatment Regimens in Computerized Prescriber Order Entry Systems

PURPOSE

Systemic treatment (ST) computerized prescriber order entry (CPOE) and preprinted orders (PPO) are proven to reduce errors. There is no known guidance in oncology to facilitate high-quality, accurate regimen development and review; hence, this was identified as a system-wide gap. This provincial initiative aimed to improve the quality of oncology regimens through a comprehensive review of systemic treatment (ST) regimens and the development of standards.

METHODS

A system-wide analysis of all active regimens (both CPOE and PPO) to ensure they were built as intended was conducted in 2015. Thirty-five hospitals (on behalf of 75 treatment facilities) were asked to report any unintentional discrepancies and details of the maintenance review process. Discrepancies were compiled, categorized, and analyzed for potential to cause harm. In addition, a multidisciplinary expert working group was formed to create best practice recommendations.

RESULTS

The review yielded a 94% response rate and took a total of 18 months to complete (70% completed within 9 months). The average number of regimens reviewed was 336 (range, 15 to 700; n = 9). Unintentional discrepancies were reported by nine hospitals (27%). A total of 369 discrepancies were reported (average, 55 per hospital), and 28 were deemed to have a moderate potential for harm. Only two hospitals (6%) had an established maintenance process; now, all have standard processes for review. Consensus-based recommendations for ST-CPOE and PPO regimen development and maintenance were developed.

CONCLUSION

The review identified unintentional discrepancies and, because of the potential for patient harm, corrective action has been taken. Identified discrepancies have been amended, and standard regimen development and maintenance review processes are now implemented system-wide to improve the quality and safety of systemic treatment delivery.

The impact of a computerized physician order entry system on medical errors with antineoplastic drugs 5 years after its implementation

WHAT IS KNOWN AND OBJECTIVE

Computerized physician order entry (CPOE) systems reduce medical errors (MEs). Nevertheless, a CPOE system may also lead to new types of errors, especially when it is first implemented. The objectives of this study were to determine the impact of a CPOE on the number of MEs and to identify the types of MEs in prescriptions issued by the Haematology Department 5 years after the implementation of the CPOE system.

METHODS

We conducted a prospective analytical study on the implementation of a CPOE system at the Pharmacy Department of the Hospital Ramon y Cajal (Madrid, Spain). The study comprised three phases: a pre-implementation phase, an implementation phase conducted in the Haematology Department and a post-implementation phase, which was conducted 5 years after the implementation of the CPOE system. One hundred and fifty prescriptions per pre- and post-implementation phase were consecutively included in the study. A previously described classification scheme was used to detect and classify MEs.

RESULTS AND DISCUSSION

The implementation of a CPOE system was associated with a large reduction in MEs. One hundred and fourteen patients (pre-implementation phase) were compared to 82 patients (post-implementation phase). The total number of MEs per 100 patients decreased from 236·8 (95% CI: 212·1-261·3) to 10·9 (95% CI: 5·8-19·6), with an absolute risk reduction of 36·2 (95% CI: 32·6-39·9). The percentage of prescriptions with an ME decreased from 37·5% to 1·2% (P < 0.001). In the pre-implementation phase, the drugs most frequently associated with MEs were rituximab (35·9%), cyclophosphamide (13%) and methotrexate (7%). In the post-implementation phase, 44·4% of prescription errors involved methotrexate. Five years after the implementation of the CPOE system, the majority of MEs were eliminated, the number of remaining errors (quantity, concentration and ambiguous prescription errors) decreased, and no new types of ME were detected.

WHAT IS NEW AND CONCLUSION

The CPOE system almost completely eliminated MEs with antineoplastic drugs in the Haematology Department. No new types of MEs were observed once physicians had become accustomed to using the system. However, some MEs were not eliminated. Constant diligence is needed to analyse and evaluate MEs associated with the CPOE system and their causes, such that the limitations of CPOE can be identified and overcome and the medication-use process associated with antineoplastic agents improved.

Chemotherapy e-prescribing: opportunities and challenges

Chemotherapy drugs are characterized by low therapeutic indices and significant toxicities at clinically prescribed doses, raising serious issues of drug safety. The safety of the chemotherapy medication use process is further challenged by regimen complexity and need to tailor treatment to patient status. Errors that occur during chemotherapy prescribing are associated with serious and life-threatening outcomes. Computerized provider order entry (CPOE) systems were shown to reduce overall medication errors in ambulatory and inpatient settings. The adoption of chemotherapy CPOE is lagging due to financial cost and cultural and technological challenges. Institutions that adopted infusional or oral chemotherapy electronic prescribing modified existing CPOE systems to allow chemotherapy prescribing, implemented chemotherapy-specific CPOE systems, or developed home-grown chemotherapy electronic prescribing programs. Implementation of chemotherapy electronic prescribing was associated with a significant reduction in the risk of prescribing errors, most significantly dose calculation and adjustment errors. In certain cases, implementation of chemotherapy CPOE was shown to improve the chemotherapy use process. The implementation of chemotherapy CPOE may increase the risk of new types of errors, especially if processes are not redesigned and adapted to CPOE. Organizations aiming to implement chemotherapy CPOE should pursue a multidisciplinary approach engaging all stakeholders to guide system selection and implementation. Following implementation, organizations should develop and use a risk assessment process to identify and evaluate unanticipated consequences and CPOE-generated errors. The results of these analyses should serve to further enhance the chemotherapy electronic prescribing process and improve the quality and safety of cancer care.

Interventions for reducing medication errors in children in hospital

BACKGROUND

Many hospitalised patients are affected by medication errors (MEs) that may cause discomfort, harm and even death. Children are at especially high risk of harm as the result of MEs because such errors are potentially more hazardous to them than to adults. Until now, interventions to reduce MEs have led to only limited improvements.

OBJECTIVES

To determine the effectiveness of interventions aimed at reducing MEs and related harm in hospitalised children.

SEARCH METHODS

The Effective Practice and Organisation of Care Group (EPOC) Trials Search Co-ordinator searched the following sources for primary studies: The Cochrane Library, including the Cochrane Central Register of Controlled Trials (CENTRAL), the Economic Evaluation Database (EED) and the Health Technology Assessments (HTA) database; MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Proquest Dissertations & Theses, Web of Science (citation indexes and conference proceedings) and the EPOC Register of Studies. Related reviews were identified by searching the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects (DARE). Review authors searched grey literature sources and trial registries. They handsearched selected journals, contacted researchers in the field and scanned reference lists of relevant reviews. They conducted searches in November 2013 and November 2014. They applied neither language nor date limits.

SELECTION CRITERIA

Randomised controlled trials, controlled before-after studies and interrupted time series investigating interventions to improve medication safety in hospitalised children (≤ 18 years). Participants were healthcare professionals authorised to prescribe, dispense or administer medications. Outcome measures included MEs, (potential) patient harm, resource utilisation and unintended consequences of the interventions.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed study quality using the EPOC data collection checklist. We evaluated the risk of bias of included studies and used the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach to assess the quality of the body of evidence. We described results narratively and presented them using GRADE tables.

MAIN RESULTS

We included seven studies describing five different interventions: participation of a clinical pharmacist in a clinical team (n = 2), introduction of a computerised physician order entry system (n = 2), implementation of a barcode medication administration system (n = 1), use of a structured prescribing form (n = 1) and implementation of a check and control checklist in combination with feedback (n = 1).Clinical and methodological heterogeneity between studies precluded meta-analyses. Although some interventions described in this review show a decrease in MEs, the results are not consistent, and none of the studies resulted in a significant reduction in patient harm. Based on the GRADE approach, the overall quality and strengfh of the evidence are low.

AUTHORS' CONCLUSIONS

Current evidence on effective interventions to prevent MEs in a paediatric population in hospital is limited. Comparative studies with robust study designs are needed to investigate interventions including components that focus on specific paediatric safety issues.

Non-intercepted dose errors in prescribing anti-neoplastic treatment: a prospective, comparative cohort study

BACKGROUND

The incidence of non-intercepted prescription errors and the risk factors involved, including the impact of computerised order entry (CPOE) systems on such errors, are unknown. Our objective was to determine the incidence, type, severity, and related risk factors of non-intercepted prescription dose errors.

PATIENTS AND METHODS

A prospective, comparative cohort study in two clinical oncology units. One institution used a CPOE system with no connection to the electronic patient record system, while the other used paper-based prescription forms. All standard prescriptions were included and reviewed. Doses were recalculated according to the guidelines of each institution, using the patient data as documented in the patient record, the paper-based prescription form, or the CPOE system. A non-intercepted prescription dose error was defined as ≥10% difference between the administered and the recalculated dose.

RESULTS

Data were collected from 1 November 2012 to 15 January 2013. A total of 5767 prescriptions were evaluated, 2677 from the institution using CPOE and 3090 from the institution with paper-based prescription. Crude analysis showed an overall risk of a prescription dose error of 1.73 per 100 prescriptions. CPOE resulted in 1.60 and paper-based prescription forms in 1.84 errors per 100 prescriptions, i.e. odds ratio (OR) = 0.87 [95% confidence interval (CI) 0.59-1.29, P = 0.49]. Fifteen different types of errors and four potential risk factors were identified. None of the dose errors resulted in the death of the patient.

CONCLUSIONS

Non-intercepted prescribing dose errors occurred in <2% of the prescriptions. The parallel CPOE system did not significantly reduce the overall risk of dose errors, and although it reduced the risk of calculation errors, it introduced other errors. Strategies to prevent future prescription errors could usefully focus on integrated computerised systems that can aid dose calculations and reduce transcription errors between databases.