Computerized provider order entry-related medication errors among hospitalized patients: An integrative review

Longitudinal study of the manifestations and mechanisms of technology-related prescribing errors in pediatrics

OBJECTIVES

To examine changes in technology-related errors (TREs), their manifestations and underlying mechanisms at 3 time points after the implementation of computerized provider order entry (CPOE) in an electronic health record; and evaluate the clinical decision support (CDS) available to mitigate the TREs at 5-years post-CPOE.

MATERIALS AND METHODS

Prescribing errors (n = 1315) of moderate, major, or serious potential harm identified through review of 35 322 orders at 3 time points (immediately, 1-year, and 4-years post-CPOE) were assessed to identify TREs at a tertiary pediatric hospital. TREs were coded using the Technology-Related Error Mechanism classification. TRE rates, percentage of prescribing errors that were TREs, and mechanism rates were compared over time. Each TRE was tested in the CPOE 5-years post-implementation to assess the availability of CDS to mitigate the error.

RESULTS

TREs accounted for 32.5% (n = 428) of prescribing errors; an adjusted rate of 1.49 TREs/100 orders (95% confidence interval [CI]: 1.06, 1.92). At 1-year post-CPOE, the rate of TREs was 40% lower than immediately post (incident rate ratio [IRR]: 0.60; 95% CI: 0.41, 0.89). However, at 4-years post, the TRE rate was not significantly different to baseline (IRR: 0.80; 95% CI: 0.59, 1.08). "New workflows required by the CPOE" was the most frequent TRE mechanism at all time points. CDS was available to mitigate 32.7% of TREs.

DISCUSSION

In a pediatric setting, TREs persisted 4-years post-CPOE with no difference in the rate compared to immediately post-CPOE.

CONCLUSION

Greater attention is required to address TREs to enhance the safety benefits of systems.

Improving the interoperability of drugs terminologies: Infusing local standardization with an international perspective

OBJECTIVES

The objective of this study is to describe how OCRx (Canadian Drug Ontology) has been built to address the dual need for local drug information integration in Canada and alignment with international standards requirements.

METHODS

This paper delves into (i) the implementation efforts to meet the Identification of Medicinal Product (IDMP) requirements in OCRx, alongside the ontology update strategy, (ii) the structure of the ontology itself, (iii) the alignment approach with several reference Knowledge Organization Systems, including SNOMED CT, RxNorm, and the list of "Code Identifiant de Spécialité" (CIS-Code), and (iv) the look-up services developed to facilitate its access and utilization.

RESULTS

Each OCRx release contains two distinct versions: the full and the up-to-date version. The full version encompasses all drugs with a DIN code sanctioned by Health Canada, while the up-to-date version is limited to drugs currently marketed in Canada. In the last release of OCRx, the full version comprises 162,400 classes; meanwhile, the up-to-date version consists of 36,909 classes. In terms of mappings with OCRx, substances in RxNorm and SNOMED CT fall below 40%, registering at 37% and 22% respectively. Meanwhile, mappings for CIS-Code achieve coverage of 61%. The strength mappings are notably low for RxNorm at 40% and for CIS-code at 28%. This affects the mapping of clinical drugs, which are predominantly alignable through post-coordinated expressions: 56% for RxNorm, 80% for SNOMED CT, and 35% for CIS-Code. The main support service of OCRx is a look-up service known as PaperRx that displays OCRx's entities based on description logic queries (DL-queries) performed through the classified structure of OCRx. The look-up services also contain a SPARQL endpoint, an OCRx OWL file downloader, and a RESTful API.

DISCUSSION

The OCRx ontology demonstrates a significant effort towards integrating Canadian drug information with international standards. However, there are areas for improvement. In the future, our focus will be on refining the structure of OCRx for better classification capability and improvement of dosage conversion. Additionally, we aim to harness OCRx in constructing an ontology-based annotator, setting our sights on its deployment in real-world data integration scenarios.

[Inability of hospital computerised physician order entry systems to secure the use of concentrated potassium intravenous solutions]

OBJECTIVES

To determine whether hospital computerised physician order entry (CPOE) systems contribute to securing intravenous potassium chloride (KCl) prescriptions with reference to the recommendations issued by French healthcare agencies.

METHODS

We sent a questionnaire to the members of the Association pour le Digital et l'Information en Pharmacie.

RESULTS

More than three quarters of the 84 responses received involving 23 CPOE systems indicate that it is possible to: prescribe an ampoule of concentrated potassium chloride 10% 10mL intravenously without any diluents (80%); prescribe 4g of KCl in a bag of 500mL of NaCl 0,9% (98%); prescribe a solution that contains 6 grams of KCl per liter (94%); prescribe the administration of an injectable ampoule orally by means of a free text comment (83%). Nearly half of the responses indicate that it is possible to prescribe: concentrated KCl ampoules as administration solvent (50%); an injectable vial to be administered by oral route (52%).

CONCLUSION

At least 23 hospital CPOE systems are unable to secure the prescriptions of injectable KCl. This finding lifts the veil on an unthought, namely the role of CPOE systems in securing high-risk medications. In order to solve this problem, it should be mandatory that health information technology vendors pay particular attention to these drugs. With regard to injectable KCl, the utilisation of a dilution vehicle, maximum concentration and maximum infusion flow rate are the first four constraints to be satisfied.

Unintended consequences of pharmacy information systems: A case study

BACKGROUND

Pharmacy information systems (PhIS) can cause medication errors that pharmacists may overlook due to their increased workload and lack of understanding of maintaining information quality. This study seeks to identify factors influencing unintended consequences of PhIS and how they affect the information quality, which can pose a risk to patient safety.

MATERIALS AND METHODS

This qualitative, explanatory case study evaluated PhIS in ambulatory pharmacies in a hospital and a clinic. Data were collected through observations, interviews, and document analysis. We applied the socio-technical interactive analysis (ISTA) framework to investigate the socio-technical interactions of pharmacy information systems that lead to unintended consequences. We then adopted the human-organization-process-technology-fit (HOPT-fit) framework to identify their contributing and dominant factors, misfits, and mitigation measures.

RESULTS

We identified 28 unintended consequences of PhIS, their key contributing factors, and their interrelations with the systems. The primary causes of unintended consequences include system rigidity and complexity, unclear knowledge, understanding, skills, and purpose of using the system, use of hybrid paper and electronic documentation, unclear and confusing transitions, additions and duplication of tasks and roles in the workflow, and time pressure, causing cognitive overload and workarounds. Recommended mitigating mechanisms include human factor principles in system design, data quality improvement for PhIS in terms of effective use of workspace, training, PhIS master data management, and communication by standardizing workarounds.

CONCLUSION

Threats to information quality emerge in PhIS because of its poor design, a failure to coordinate its functions and clinical tasks, and pharmacists' lack of understanding of the system use. Therefore, safe system design, fostering awareness in maintaining the information quality of PhIS and cultivating its safe use in organizations is essential to ensure patient safety. The proposed evaluation approach facilitates the evaluator to identify complex socio-technical interactions and unintended consequences factors, impact, and mitigation mechanisms.

Intercepting Medication Errors in Pediatric In-patients Using a Prescription Pre-audit Intelligent Decision System: A Single-center Study

OBJECTIVES

Medication errors can happen at any phase of the medication process at health care settings. The objective of this study is to identify the characteristics of severe prescribing errors at a pediatric hospital in the inpatient setting and to provide recommendations to improve medication safety and rational drug use.

METHODS

This descriptive retrospective study was conducted at a tertiary pediatric hospital using data collected from Jan. 1st, 2019 to Dec. 31st, 2020. During this period, the Prescription Pre-audit Intelligent Decision System was implemented. Medication orders with potential severe errors would trigger a Level 7 alert and would be intercepted before it reached the pharmacy. Trained pharmacists maintained the system and facilitated decision making when necessary. For each order intercepted by the system the following patient details were recorded and analyzed: patient age, patient's department, drug classification, dosage forms, route of administration, and the type of error.

RESULTS

A total of 2176 Level 7 medication orders were intercepted. The most common errors were associated with drug dosage, administration route, and dose frequency, accounting for 35.2%, 32.8% and 13.2%, respectively. Of all the intercepted oerrors. 53.6% occurred in infants aged < 1 year. Administration routes involved were mainly intravenous, oral and external use drugs. Most alerts came from the neonatology department and constituted 40.5% of the total alerts, followed by the nephrology department 15.9% and pediatric intensive care unit (PICU) 11.3%. As to dosage forms, injections accounted for 50.4% of alerts, with 21.3% attributable to topical solutions, 9.1% to tablets, and 5.7% to inhalation. Anti-infective agents were the most common therapeutic drugs prescribed with errors.

CONCLUSIONS

The Prescription Pre-audit Intelligent Decision System, with the supervision of trained pharmacists can validate prescriptions, increase prescription accuracy, and improve drug safety for hospitalized children. It is a medical service model worthy of consideration.

Efficiency and Safety of Electronic Health Records in Switzerland-A Comparative Analysis of 2 Commercial Systems in Hospitals

OBJECTIVES

Differences in efficiency and safety between 2 electronic health record (systems A and B) in Swiss hospitals were investigated.

METHODS

In a scenario-based usability test under experimental conditions, a total of 100 physicians at 4 hospitals were asked to complete typical routine tasks, like medication or imaging orders. Differences in number of mouse clicks and time-on-task as indicators of efficiency and error type, error count, and rate as indicators of patient safety between hospital sites were analyzed. Time-on-task and clicks were correlated with error count.

RESULTS

There were differences in efficiency and safety between hospitals. Overall, physicians working with system B required less clicks (A: 511, B: 442, P = 0.001) and time (A: 2055 seconds, B: 1713 seconds, P = 0.055) and made fewer errors (A: 40%, B: 27%, P < 0.001). No participant completed all tasks correctly. The most frequent error in medication and radiology ordering was a wrong dose and a wrong level, respectively. Time errors were particularly prevalent in laboratory orders. Higher error counts coincided with longer time-on-task (r = 0.50, P < 0.001) and more clicks (r = 0.47, P < 0.001).

CONCLUSIONS

The variations in clicks, time, and errors are likely due to naive functionality and design of the systems and differences in their implementation. The high error rates coincide with inefficiency and jeopardize patient safety and produce economic costs and burden on physicians. The results raise usability concerns with potential for severe patient harm. A deeper understanding of differences as well as regulative guidelines and policy making are needed.

Stakeholder perspectives of system-related errors: Types, contributing factors, and consequences

BACKGROUND

Despite growing evidence of the benefits of electronic medication management systems (EMMS), research has also identified a range of new safety risks linked with their use. There is limited qualitative research focusing on system-related errors that result from use of EMMS. The aim of this study was to explore in-depth stakeholders' perceptions and experiences of system-related errors.

METHODS

Semi-structured interviews were conducted with EMMS users and other relevant staff (e.g. supporting roles in EMMS) across a local health district in Sydney, Australia. Analysis was conducted iteratively using a general inductive approach, and then mapped to Reason's accident causation model, where codes were categorized as 1) unsafe acts (i.e. what error occurred), 2) latent conditions (i.e. what factors contributed to errors), and 3) consequences resulting from the error.

RESULTS

Twenty-five participants were interviewed between September 2020 and May 2021. Participants most frequently described omission errors (e.g. failure to check for duplicate orders) as unsafe acts, although commission errors and workarounds were also reported. Poor EMMS design was reported to be a significant workplace factor contributing to system-related errors, however participants also described user factors, such as an overreliance on the system, and organizational factors, such as system downtime, as contributing to errors. Reported consequences of system-related errors included medication errors, but also impacts to the EMMS and on workers.

CONCLUSIONS

EMMS design is a significant contributor to system-related errors, but this research showed that user and organizational factors are also at play. As these factors are not independent, minimizing system-related errors requires a multi-faceted approach, where mitigation strategies target not only the EMMS, but also the context in which the system has been implemented.

Implementing computerized physician order entry in a public tertiary care hospital

It is reported that at least one medication error per day occurs in hospitalized patients. Medication errors are not only harmful but also expensive. Prescription review by pharmacists is the standard to reduce prescribing error; however, due to the manual process, pharmacists lack time to conduct prescription reviews. Computerized physician order entry (CPOE) allows clinicians to directly place medication orders electronically, transmitted directly to the pharmacy. Successfully implemented CPOE systems improve the prescribing process and result in fewer medication errors. However, regardless of its significance, implementation of CPOE is a very difficult task, particularly in a public-sector hospital. Lady Reading Hospital-Medical Teaching Institution has a manual system for indenting medication system; pharmacists could only ensure the current dispensing of medication, but lack time and information to conduct a review to ensure the appropriateness of prescription. The article entails the barriers and the process of implementation of e-prescribing.