Impact of workflow-integrated corollary orders on aminoglycoside monitoring in children

Impact of Computerized Prescription on Medication Errors and Workflow Efficiency in Neonatal Intensive Care Units: A Quasi-Experimental Three-Phase Study

BACKGROUND

Neonates are highly vulnerable to preventable medication errors due to their extensive exposure to medications in the neonatal intensive care units (NICUs). These errors, which can be made by medical, nursing, or pharmacy personnel, are costly and can be life-threatening. This study aimed to investigate the newly developed computerized neonatal pharmaceutical health care system (NPHCS) in terms of its ability to (1) minimize neonatal medication prescription errors (NMPEs) and (2) improve workflow efficiency compared with the traditional manual prescribing approach.

METHODS

A computerized neonatal medication prescription system was designed, developed, and tested successfully through a pilot clinical trial for over 6 months in 100 neonates. A three phase quasi-experimental study was then conducted using standardized monitoring checklists for the assessment of NMPEs before and after utilization of the developed prescribing system.

RESULTS

The obtained result showed a high rate of NMPEs in both systems, especially for the antibiotic drug group. However, the use of newly developed NPHCS significantly improved workflow efficacy. The identified errors were significantly more common in the manual mode than in the computerized mode (158.8 vs. 55 per 100 medications). These errors were distributed among different categories, including the documentation of patient identity, birth weight, and gestational age, as well as statements of dose, unit, interval, and diagnosis. Analysis of variance across different categories showed a p-value of <0.05.

CONCLUSION

The use of the computerized NPHCS improved patient safety in NICUs by decreasing NMPEs. It also significantly reduced the time required for dose calculation, prescription generation, and electronic documentation of medical records, compared with the traditional handwritten approach.

Factors contributing to medication errors made when using computerized order entry in pediatrics: a systematic review

Objective

To identify and understand the factors that contribute to medication errors associated with the use of computerized provider order entry (CPOE) in pediatrics and provide recommendations on how CPOE systems could be improved.

Materials and Methods

We conducted a systematic literature review across 3 large databases: the Cumulative Index to Nursing and Allied Health Literature, Embase, and Medline. Three independent reviewers screened the titles, and 2 authors then independently reviewed all abstracts and full texts, with 1 author acting as a constant across all publications. Data were extracted onto a customized data extraction sheet, and a narrative synthesis of all eligible studies was undertaken.

Results

A total of 47 articles were included in this review. We identified 5 factors that contributed to errors with the use of a CPOE system: (1) lack of drug dosing alerts, which failed to detect calculation errors; (2) generation of inappropriate dosing alerts, such as warnings based on incorrect drug indications; (3) inappropriate drug duplication alerts, as a result of the system failing to consider factors such as the route of administration; (4) dropdown menu selection errors; and (5) system design issues, such as a lack of suitable dosing options for a particular drug.

Discussion and Conclusions

This review highlights 5 key factors that contributed to the occurrence of CPOE-related medication errors in pediatrics. Dosing support is the most important. More advanced clinical decision support that can suggest doses based on the drug indication is needed.

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.

Clinical Practice Guideline: Safe Medication Use in the ICU

OBJECTIVE

To provide ICU clinicians with evidence-based guidance on safe medication use practices for the critically ill.

DATA SOURCES

PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, Scopus, and ISI Web of Science for relevant material to December 2015.

STUDY SELECTION

Based on three key components: 1) environment and patients, 2) the medication use process, and 3) the patient safety surveillance system. The committee collectively developed Population, Intervention, Comparator, Outcome questions and quality of evidence statements pertaining to medication errors and adverse drug events addressing the key components. A total of 34 Population, Intervention, Comparator, Outcome questions, five quality of evidence statements, and one commentary on disclosure was developed.

DATA EXTRACTION

Subcommittee members were assigned selected Population, Intervention, Comparator, Outcome questions or quality of evidence statements. Subcommittee members completed their Grading of Recommendations Assessment, Development, and Evaluation of the question with his/her quality of evidence assessment and proposed strength of recommendation, then the draft was reviewed by the relevant subcommittee. The subcommittee collectively reviewed the evidence profiles for each question they developed. After the draft was discussed and approved by the entire committee, then the document was circulated among all members for voting on the quality of evidence and strength of recommendation.

DATA SYNTHESIS

The committee followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation system to determine quality of evidence and strength of recommendations.

CONCLUSIONS

This guideline evaluates the ICU environment as a risk for medication-related events and the environmental changes that are possible to improve safe medication use. Prevention strategies for medication-related events are reviewed by medication use process node (prescribing, distribution, administration, monitoring). Detailed considerations to an active surveillance system that includes reporting, identification, and evaluation are discussed. Also, highlighted is the need for future research for safe medication practices that is specific to critically ill patients.

A systematic review of the effectiveness of interruptive medication prescribing alerts in hospital CPOE systems to change prescriber behavior and improve patient safety

OBJECTIVES

To assess the evidence of the effectiveness of different categories of interruptive medication prescribing alerts to change prescriber behavior and/or improve patient outcomes in hospital computerized provider order entry (CPOE) systems.

METHODS

PubMed, Embase, CINAHL and the Cochrane Library were searched for relevant articles published between January 2000 and February 2016. Studies were included if they compared the outcomes of automatic, interruptive medication prescribing alert/s to a control/comparison group to determine alert effectiveness.

RESULTS

Twenty-three studies describing 32 alerts classified into 11 alert categories were identified. The most common alert categories studied were drug-condition interaction (n=6), drug-drug interaction alerts (n=6) and corollary order alerts (n=6). All 23 papers investigated the effect of the intervention alert on at least one outcome measure of prescriber behavior. Just over half of the studies (53%, n=17) reported a statistically significant beneficial effect from the intervention alert; 34% (n=11) reported no statistically significant effect, and 6% (n=2) reported a significant detrimental effect. Two studies also evaluated the effect of alerts on patient outcome measures; neither finding that patient outcomes significantly improved following alert implementation (6%, n=2). The greatest volume of evidence relates to three alert categories: drug-condition, drug-drug and corollary order alerts. Of these, drug-condition alerts had the greatest number of studies reporting positive effects (five out of six studies). Only two of six studies of drug-drug interaction and one of six of corollary alerts reported positive benefits.

DISCUSSION AND CONCLUSION

The current evidence-base does not show a clear indication that particular categories of alerts are more effective than others. While the majority of alert categories were shown to improve outcomes in some studies, there were also many cases where outcomes did not improve. This lack of evidence hinders decisions about the amount and type of decision support that should be integrated into CPOE systems to increase safety while reducing the risk of alert fatigue. Virtually no studies have sought to investigate the impact on changes to prescriber behavior and outcomes overall when alerts from multiple categories are incorporated within the same system.

Systematic Review of Medical Informatics-Supported Medication Decision Making

This systematic review sought to assess the applications and implications of current medical informatics-based decision support systems related to medication prescribing and use. Studies published between January 2006 and July 2016 which were indexed in PubMed and written in English were reviewed, and 39 studies were ultimately included. Most of the studies looked at computerized provider order entry or clinical decision support systems. Most studies examined decision support systems as a means of reducing errors or risk, particularly associated with medication prescribing, whereas a few studies evaluated the impact medical informatics-based decision support systems have on workflow or operations efficiency. Most studies identified benefits associated with decision support systems, but some indicate there is room for improvement.

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.

Reduction in Clinical Variance Using Targeted Design Changes in Computerized Provider Order Entry (CPOE) Order Sets: Impact on Hospitalized Children with Acute Asthma Exacerbation

OBJECTIVES

Unwarranted variance in healthcare has been associated with prolonged length of stay, diminished health and increased cost. Practice variance in the management of asthma can be significant and few investigators have evaluated strategies to reduce this variance. We hypothesized that selective redesign of order sets using different ways to frame the order and physician decision-making in a computerized provider order entry system could increase adherence to evidence-based care and reduce population-specific variance.

PATIENTS AND METHODS

The study focused on the use of an evidence-based asthma exacerbation order set in the electronic health record (EHR) before and after order set redesign. In the Baseline period, the EHR was queried for frequency of use of an asthma exacerbation order set and its individual orders. Important individual orders with suboptimal use were targeted for redesign. Data from a Post-Intervention period were then analyzed.

RESULTS

In the Baseline period there were 245 patient visits in which the acute asthma exacerbation order set was selected. The utilization frequency of most orders in the order set during this period exceeded 90%. Three care items were targeted for intervention due to suboptimal utilization: admission weight, activity center use and peak flow measurements. In the Post-Intervention period there were 213 patient visits. Order set redesign using different default order content resulted in significant improvement in the utilization of orders for all 3 items: admission weight (79.2% to 94.8% utilization, p<0.001), activity center (84.1% to 95.3% utilization, p<0.001) and peak flow (18.8% to 55.9% utilization, p<0.001). Utilization of peak flow orders for children ≥8 years of age increased from 42.7% to 94.1% (p<0.001).

CONCLUSIONS

Details of order set design greatly influence clinician prescribing behavior. Queries of the EHR reveal variance associated with ordering frequencies. Targeting and changing order set design elements in a CPOE system results in improved selection of evidence-based care.

Computer-related medication errors in neonatal intensive care units

Iatrogenic medication errors in the neonatal ICU (NICU) are reported to occur up to 2.6 times per 100 NICU days. It has been learned during the last decade that well-intended but faulty implementations of technology can increase the frequency of errors and also can give rise to new types. This article compares and discusses iatrogenic medication errors in the NICU that are related to computer entry and computerized physician order entry systems. The authors also propose a possible approach for evaluating technology that is intended to prevent iatrogenic mediation errors in the NICU.

Interventions to reduce dosing errors in children: a systematic review of the literature

Children are a particularly challenging group of patients when trying to ensure the safe use of medicines. The increased need for calculations, dilutions and manipulations of paediatric medicines, together with a need to dose on an individual patient basis using age, gestational age, weight and surface area, means that they are more prone to medication errors at each stage of the medicines management process. It is already known that dose calculation errors are the most common type of medication error in neonatal and paediatric patients. Interventions to reduce the risk of dose calculation errors are therefore urgently needed. A systematic literature review was conducted to identify published articles reporting interventions; 28 studies were found to be relevant. The main interventions found were computerised physician order entry (CPOE) and computer-aided prescribing. Most CPOE and computer-aided prescribing studies showed some degree of reduction in medication errors, with some claiming no errors occurring after implementation of the intervention. However, one study showed a significant increase in mortality after the implementation of CPOE. Further research is needed to investigate outcomes such as mortality and economics. Unit dose dispensing systems and educational/risk management programmes were also shown to reduce medication errors in children. Although it is suggested that 'smart' intravenous pumps can potentially reduce infusion errors in children, there is insufficient information to draw a conclusion because of a lack of research. Most interventions identified were US based, and since medicine management processes are currently different in different countries, there is a need to interpret the information carefully when considering implementing interventions elsewhere.

Electronic medical record, error detection, and error reduction: a pediatric critical care perspective

INTRODUCTION

Automated extraction of data from computer-based medical records for use in quality improvement has been described for >20 yrs.

OBJECTIVE

This article reviews the role of the electronic medical record in automating adverse event detection in the study of medication errors, nosocomial infection, and in the perioperative setting. In addition, the use of the electronic medical record in the detection and reduction of delays in STAT (at once) radiology testing and respiratory therapy treatment will be reviewed.

CONCLUSION

The electronic medical record, including computerized provider order entry, can have an important effect on medical error detection and reduction.