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Dahmke H, Cabrera-Diaz F, Heizmann M, Stoop S, Schuetz P, Fiumefreddo R, Zaugg C. Development and validation of a clinical decision support system to prevent anticoagulant duplications. Int J Med Inform 2024; 187:105446. [PMID: 38669733 DOI: 10.1016/j.ijmedinf.2024.105446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 03/28/2024] [Accepted: 04/04/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND AND OBJECTIVE Unintended duplicate prescriptions of anticoagulants increase the risk of serious adverse events. Clinical Decision Support Systems (CDSSs) can help prevent such medication errors; however, sophisticated algorithms are needed to avoid alert fatigue. This article describes the steps taken in our hospital to develop a CDSS to prevent anticoagulant duplication (AD). METHODS The project was composed of three phases. In phase I, the status quo was established. In phase II, a clinical pharmacist developed an algorithm to detect ADs using daily data exports. In phase III, the algorithm was integrated into the hospital's electronic health record system. Alerts were reviewed by clinical pharmacists before being sent to the prescribing physician. We conducted a retrospective analysis of all three phases to assess the impact of the interventions on the occurrence and duration of ADs. Phase III was analyzed in more detail regarding the acceptance rate, sensitivity, and specificity of the alerts. RESULTS We identified 91 ADs in 1581 patients receiving two or more anticoagulants during phase I, 70 ADs in 1692 patients in phase II, and 57 ADs in 1575 patients in phase III. Mean durations of ADs were 1.8, 1.4, and 1.1 calendar days during phases I, II, and III, respectively. In comparison to the baseline in phase I, the relative risk reduction of AD in patients treated with at least two different anticoagulants during phase III was 42% (RR: 0.58, CI: 0.42-0.81). A total of 429 alerts were generated during phase III, many of which were self-limiting, and 186 alerts were sent to the respective prescribing physician. The acceptance rate was high at 97%. We calculated a sensitivity of 87.4% and a specificity of 87.9%. CONCLUSION The stepwise development of a CDSS for the detection of AD markedly reduced the frequency and duration of medication errors in our hospital, thereby improving patient safety.
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Affiliation(s)
- Hendrike Dahmke
- Hospital Pharmacy, Kantonsspital Aarau, 5000 Aarau, Switzerland.
| | | | - Marc Heizmann
- Division of Oncology, Haematology and Transfusion Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Sophie Stoop
- Department of Chemistry and Applied Biosciences, Eidgenossische Technische Hochschule Zürich, Zurich, Switzerland
| | - Philipp Schuetz
- Department of Internal Medicine, Kantonsspital Aarau, 5000 Aarau, Switzerland
| | - Rico Fiumefreddo
- Department of Internal Medicine, Kantonsspital Aarau, 5000 Aarau, Switzerland
| | - Claudia Zaugg
- Hospital Pharmacy, Kantonsspital Aarau, 5000 Aarau, Switzerland
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Sundermann M, Clendon O, McNeill R, Doogue M, Chin PKL. Optimising interruptive clinical decision support alerts for antithrombotic duplicate prescribing in hospital. Int J Med Inform 2024; 186:105418. [PMID: 38518676 DOI: 10.1016/j.ijmedinf.2024.105418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 03/05/2024] [Accepted: 03/17/2024] [Indexed: 03/24/2024]
Abstract
INTRODUCTION Duplicate prescribing clinical decision support alerts can prevent important prescribing errors but are frequently the cause of much alert fatigue. Stat dose prescriptions are a known reason for overriding these alerts. This study aimed to evaluate the effect of excluding stat dose prescriptions from duplicate prescribing alerts for antithrombotic medicines on alert burden, prescriber adherence, and prescribing. MATERIALS AND METHODS A before (January 1st, 2017 to August 31st, 2022) and after (October 5th, 2022 to September 30th, 2023) study was undertaken of antithrombotic duplicate prescribing alerts and prescribing following a change in alert settings. Alert and prescribing data for antithrombotic medicines were joined, processed, and analysed to compare alert rates, adherence, and prescribing. Alert burden was assessed as alerts per 100 prescriptions. Adherence was measured at the point of the alert as whether the prescriber accepted the alert and following the alert as whether a relevant prescription was ceased within an hour. Co-prescribing of antithrombotic stat dose prescriptions was assessed pre- and post-alert reconfiguration. RESULTS Reconfiguration of the alerts reduced the alert rate by 29 % (p < 0.001). The proportion of alerts associated with cessation of antithrombotic duplication significantly increased (32.8 % to 44.5 %, p < 0.001). Adherence at the point of the alert increased 1.2 % (4.8 % to 6.0 %, p = 0.012) and 11.5 % (29.4 % to 40.9 %, p < 0.001) within one hour of the alert. When ceased after the alert over 80 % of duplicate prescriptions were ceased within 2 min of overriding. Antithrombotic stat dose co-prescribing was unchanged for 4 out of 5 antithrombotic duplication alert rules. CONCLUSION By reconfiguring our antithrombotic duplicate prescribing alerts, we reduced alert burden and increased alert adherence. Many prescribers ceased duplicate prescribing within 2 min of alert override highlighting the importance of incorporating post-alert measures in accurately determining prescriber alert adherence.
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Affiliation(s)
- Milan Sundermann
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Olivia Clendon
- Department of Clinical Pharmacology, Te Whatu Ora Health New Zealand - Waitaha Canterbury, New Zealand
| | - Richard McNeill
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Matthew Doogue
- Department of Medicine, University of Otago, Christchurch, New Zealand; Department of Clinical Pharmacology, Te Whatu Ora Health New Zealand - Waitaha Canterbury, New Zealand
| | - Paul K L Chin
- Department of Medicine, University of Otago, Christchurch, New Zealand; Department of Clinical Pharmacology, Te Whatu Ora Health New Zealand - Waitaha Canterbury, New Zealand.
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Liu S, McCoy AB, Wright AP, Nelson SD, Huang SS, Ahmad HB, Carro SE, Franklin J, Brogan J, Wright A. Why do users override alerts? Utilizing large language model to summarize comments and optimize clinical decision support. J Am Med Inform Assoc 2024; 31:1388-1396. [PMID: 38452289 PMCID: PMC11105133 DOI: 10.1093/jamia/ocae041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 02/06/2024] [Accepted: 02/21/2024] [Indexed: 03/09/2024] Open
Abstract
OBJECTIVES To evaluate the capability of using generative artificial intelligence (AI) in summarizing alert comments and to determine if the AI-generated summary could be used to improve clinical decision support (CDS) alerts. MATERIALS AND METHODS We extracted user comments to alerts generated from September 1, 2022 to September 1, 2023 at Vanderbilt University Medical Center. For a subset of 8 alerts, comment summaries were generated independently by 2 physicians and then separately by GPT-4. We surveyed 5 CDS experts to rate the human-generated and AI-generated summaries on a scale from 1 (strongly disagree) to 5 (strongly agree) for the 4 metrics: clarity, completeness, accuracy, and usefulness. RESULTS Five CDS experts participated in the survey. A total of 16 human-generated summaries and 8 AI-generated summaries were assessed. Among the top 8 rated summaries, five were generated by GPT-4. AI-generated summaries demonstrated high levels of clarity, accuracy, and usefulness, similar to the human-generated summaries. Moreover, AI-generated summaries exhibited significantly higher completeness and usefulness compared to the human-generated summaries (AI: 3.4 ± 1.2, human: 2.7 ± 1.2, P = .001). CONCLUSION End-user comments provide clinicians' immediate feedback to CDS alerts and can serve as a direct and valuable data resource for improving CDS delivery. Traditionally, these comments may not be considered in the CDS review process due to their unstructured nature, large volume, and the presence of redundant or irrelevant content. Our study demonstrates that GPT-4 is capable of distilling these comments into summaries characterized by high clarity, accuracy, and completeness. AI-generated summaries are equivalent and potentially better than human-generated summaries. These AI-generated summaries could provide CDS experts with a novel means of reviewing user comments to rapidly optimize CDS alerts both online and offline.
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Affiliation(s)
- Siru Liu
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37212, United States
- Department of Computer Science, Vanderbilt University, Nashville, TN 37212, United States
| | - Allison B McCoy
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37212, United States
| | - Aileen P Wright
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37212, United States
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37212, United States
| | - Scott D Nelson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37212, United States
| | - Sean S Huang
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37212, United States
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37212, United States
| | - Hasan B Ahmad
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA 98195, United States
| | - Sabrina E Carro
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN 37212, United States
| | - Jacob Franklin
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37212, United States
| | - James Brogan
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37212, United States
| | - Adam Wright
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37212, United States
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37212, United States
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Graafsma J, Murphy RM, van de Garde EMW, Karapinar-Çarkit F, Derijks HJ, Hoge RHL, Klopotowska JE, van den Bemt PMLA. The use of artificial intelligence to optimize medication alerts generated by clinical decision support systems: a scoping review. J Am Med Inform Assoc 2024; 31:1411-1422. [PMID: 38641410 PMCID: PMC11105146 DOI: 10.1093/jamia/ocae076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/21/2024] [Accepted: 03/28/2024] [Indexed: 04/21/2024] Open
Abstract
OBJECTIVE Current Clinical Decision Support Systems (CDSSs) generate medication alerts that are of limited clinical value, causing alert fatigue. Artificial Intelligence (AI)-based methods may help in optimizing medication alerts. Therefore, we conducted a scoping review on the current state of the use of AI to optimize medication alerts in a hospital setting. Specifically, we aimed to identify the applied AI methods used together with their performance measures and main outcome measures. MATERIALS AND METHODS We searched Medline, Embase, and Cochrane Library database on May 25, 2023 for studies of any quantitative design, in which the use of AI-based methods was investigated to optimize medication alerts generated by CDSSs in a hospital setting. The screening process was supported by ASReview software. RESULTS Out of 5625 citations screened for eligibility, 10 studies were included. Three studies (30%) reported on both statistical performance and clinical outcomes. The most often reported performance measure was positive predictive value ranging from 9% to 100%. Regarding main outcome measures, alerts optimized using AI-based methods resulted in a decreased alert burden, increased identification of inappropriate or atypical prescriptions, and enabled prediction of user responses. In only 2 studies the AI-based alerts were implemented in hospital practice, and none of the studies conducted external validation. DISCUSSION AND CONCLUSION AI-based methods can be used to optimize medication alerts in a hospital setting. However, reporting on models' development and validation should be improved, and external validation and implementation in hospital practice should be encouraged.
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Affiliation(s)
- Jetske Graafsma
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, 9713GZ, The Netherlands
| | - Rachel M Murphy
- Department of Medical Informatics Amsterdam UMC, University of Amsterdam, Amsterdam, 1000GG, The Netherlands
- Amsterdam Public Health Institute, Digital Health and Quality of Care, Amsterdam, 1105AZ, The Netherlands
| | - Ewoudt M W van de Garde
- Department of Pharmacy, St Antonius Hospital, Utrecht, 3430AM, The Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht University, Utrecht, 3584CS, The Netherlands
| | - Fatma Karapinar-Çarkit
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center, Maastricht, 6229HX, The Netherlands
- Department of Clinical Pharmacy, CARIM, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, 6229ER, The Netherlands
| | - Hieronymus J Derijks
- Department of Pharmacy, Jeroen Bosch Hospital, Den Bosch, 5200ME, The Netherlands
| | - Rien H L Hoge
- Department of Pharmacy, Wilhelmina Hospital, Assen, 9401RK, The Netherlands
| | - Joanna E Klopotowska
- Department of Medical Informatics Amsterdam UMC, University of Amsterdam, Amsterdam, 1000GG, The Netherlands
- Amsterdam Public Health Institute, Digital Health and Quality of Care, Amsterdam, 1105AZ, The Netherlands
| | - Patricia M L A van den Bemt
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, 9713GZ, The Netherlands
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Coleman JJ, Atia J, Evison F, Wilson L, Gallier S, Sames R, Capewell A, Copley R, Gyves H, Ball S, Pankhurst T. Adoption by clinicians of electronic order communications in NHS secondary care: a descriptive account. BMJ Health Care Inform 2024; 31:e100850. [PMID: 38729772 PMCID: PMC11097811 DOI: 10.1136/bmjhci-2023-100850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 02/24/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Due to the rapid advancement in information technology, changes to communication modalities are increasingly implemented in healthcare. One such modality is Computerised Provider Order Entry (CPOE) systems which replace paper, verbal or telephone orders with electronic booking of requests. We aimed to understand the uptake, and user acceptability, of CPOE in a large National Health Service hospital system. METHODS This retrospective single-centre study investigates the longitudinal uptake of communications through the Prescribing, Information and Communication System (PICS). The development and configuration of PICS are led by the doctors, nurses and allied health professionals that use it and requests for CPOE driven by clinical need have been described.Records of every request (imaging, specialty review, procedure, laboratory) made through PICS were collected between October 2008 and July 2019 and resulting counts were presented. An estimate of the proportion of completed requests made through the system has been provided for three example requests. User surveys were completed. RESULTS In the first 6 months of implementation, a total of 832 new request types (imaging types and specialty referrals) were added to the system. Subsequently, an average of 6.6 new request types were added monthly. In total, 8 035 132 orders were requested through PICS. In three example request types (imaging, endoscopy and full blood count), increases in the proportion of requests being made via PICS were seen. User feedback at 6 months reported improved communications using the electronic system. CONCLUSION CPOE was popular, rapidly adopted and diversified across specialties encompassing wide-ranging requests.
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Affiliation(s)
- Jamie J Coleman
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- University of Birmingham, Birmingham, UK
| | - Jolene Atia
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Felicity Evison
- Data Science Team, Research Development and Innovation, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Suzy Gallier
- PIONEER Health Data Research Hub, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard Sames
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Andrew Capewell
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard Copley
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Helen Gyves
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Simon Ball
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Tanya Pankhurst
- Digital Healthcare and Department of Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Klein P, Bonhomme J, Bourne C, Hellot-Guersing M, Marcucci C, Rodier S, Charpiat B. [Inability of hospital computerised physician order entry systems to secure the use of concentrated potassium intravenous solutions]. Ann Pharm Fr 2024; 82:359-368. [PMID: 37879563 DOI: 10.1016/j.pharma.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 05/29/2023] [Accepted: 06/12/2023] [Indexed: 10/27/2023]
Abstract
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.
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Affiliation(s)
- Pauline Klein
- Service pharmaceutique, hôpital de la Croix-Rousse, groupement hospitalier Nord, hospices civils de Lyon, 103, grande rue de la Croix Rousse, 69317 Lyon cedex 04, France.
| | - Jeremy Bonhomme
- OMEDIT Océan Indien - ARS La Réunion, 2bis, avenue Georges-Brassens CS 61002, 97743 Saint-Denis cedex 9, Réunion
| | - Cindy Bourne
- Service pharmaceutique, centre hospitalier de Crest, rue Paul-Goy, 26400 Crest, France
| | - Magali Hellot-Guersing
- Service pharmaceutique, centre hospitalier Lucien-Hussel, montée du Dr-Chapuis, 38200 Vienne, France
| | - Charles Marcucci
- Service pharmaceutique, centre hospitalier de Clermont de l'Oise, rue Frédéric-Raboisson, BP 40024, 60607 Clermont Cedex, France
| | - Simon Rodier
- Service pharmaceutique, centre hospitalier intercommunal Alençon-Mamers, 25, rue de Fresnay, 61000 Alençon, France
| | - Bruno Charpiat
- Service pharmaceutique, hôpital de la Croix-Rousse, groupement hospitalier Nord, hospices civils de Lyon, 103, grande rue de la Croix Rousse, 69317 Lyon cedex 04, France
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Musser RC, Senior R, Havrilesky LJ, Buuck J, Casarett DJ, Ibrahim S, Davidson BA. Randomized Comparison of Electronic Health Record Alert Types in Eliciting Responses about Prognosis in Gynecologic Oncology Patients. Appl Clin Inform 2024; 15:204-211. [PMID: 38232748 PMCID: PMC10937092 DOI: 10.1055/a-2247-9355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 01/16/2024] [Indexed: 01/19/2024] Open
Abstract
OBJECTIVES To compare the ability of different electronic health record alert types to elicit responses from users caring for cancer patients benefiting from goals of care (GOC) conversations. METHODS A validated question asking if the user would be surprised by the patient's 6-month mortality was built as an Epic BestPractice Advisory (BPA) alert in three versions-(1) Required on Open chart (pop-up BPA), (2) Required on Close chart (navigator BPA), and (3) Optional Persistent (Storyboard BPA)-randomized using patient medical record number. Meaningful responses were defined as "Yes" or "No," rather than deferral. Data were extracted over 6 months. RESULTS Alerts appeared for 685 patients during 1,786 outpatient encounters. Measuring encounters where a meaningful response was elicited, rates were highest for Required on Open (94.8% of encounters), compared with Required on Close (90.1%) and Optional Persistent (19.7%) (p < 0.001). Measuring individual alerts to which responses were given, they were most likely meaningful with Optional Persistent (98.3% of responses) and least likely with Required on Open (68.0%) (p < 0.001). Responses of "No," suggesting poor prognosis and prompting GOC, were more likely with Optional Persistent (13.6%) and Required on Open (10.3%) than with Required on Close (7.0%) (p = 0.028). CONCLUSION Required alerts had response rates almost five times higher than optional alerts. Timing of alerts affects rates of meaningful responses and possibly the response itself. The alert with the most meaningful responses was also associated with the most interruptions and deferral responses. Considering tradeoffs in these metrics is important in designing clinical decision support to maximize success.
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Affiliation(s)
- Robert Clayton Musser
- Department of Medicine, Duke University Health System, Durham, North Carolina, United States
- Duke Health Technology Solutions, Durham, North Carolina, United States
| | - Rashaud Senior
- Duke Health Technology Solutions, Durham, North Carolina, United States
- Duke Primary Care, Duke University Health System, Durham, North Carolina, United States
| | - Laura J. Havrilesky
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Health System, Durham, North Carolina, United States
| | - Jordan Buuck
- Duke Health Technology Solutions, Durham, North Carolina, United States
| | - David J. Casarett
- Section of Palliative Care, Department of Medicine, Duke University Health System, Durham, North Carolina, United States
| | - Salam Ibrahim
- Duke Health Performance Services, Duke University Health System, Durham, North Carolina, United States
| | - Brittany A. Davidson
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Health System, Durham, North Carolina, United States
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Ruutiainen H, Holmström AR, Kunnola E, Kuitunen S. Use of Computerized Physician Order Entry with Clinical Decision Support to Prevent Dose Errors in Pediatric Medication Orders: A Systematic Review. Paediatr Drugs 2024; 26:127-143. [PMID: 38243105 PMCID: PMC10891203 DOI: 10.1007/s40272-023-00614-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2023] [Indexed: 01/21/2024]
Abstract
BACKGROUND Prescribing is a high-risk task within the pediatric medication-use process and requires defenses to prevent errors. Such system-centric defenses include electronic health record systems with computerized physician order entry (CPOE) and clinical decision support (CDS) tools that assist safe prescribing. The objective of this study was to examine the effects of CPOE systems with CDS functions in preventing dose errors in pediatric medication orders. MATERIAL AND METHODS This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 criteria and Synthesis Without Meta-Analysis (SWiM) items. The study protocol was registered in PROSPERO (CRD42021277413). The final literature search on MEDLINE (Ovid), Scopus, Web of Science, and EMB Reviews was conducted on 10 September 2023. Only peer-reviewed studies considering both CPOE and CDS systems in pediatric inpatient or outpatient settings were included. Study selection, data extraction, and evidence quality assessment (JBI critical appraisal tool assessment and GRADE approach) were carried out by two individual reviewers. Vote counting method was used to evaluate the effects of CPOE-CDS systems on dose errors rates. RESULTS A total of 17 studies published in 2007-2021 met the inclusion criteria. The most used CDS tools were dose range check (n = 14), dose calculator (n = 8), and dosing frequency check (n = 8). Alerts were recorded in 15 studies. A statistically significant reduction in dose errors was found in eight studies, whereas an increase of dose errors was not reported. CONCLUSIONS The CPOE-CDS systems have the potential to reduce pediatric dose errors. Most beneficial interventions seem to be system customization, implementing CDS alerts, and the use of dose range check. While human factors are still present within the medication use process, further studies and development activities are needed to optimize the usability of CPOE-CDS systems.
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Affiliation(s)
- Henna Ruutiainen
- Division of Pharmacology and Pharmacotherapy, Faculty of Pharmacy, University of Helsinki, Viikinkaari 5 E, PL 56, 00014, Helsinki, Finland.
- HUS Pharmacy, Helsinki University Hospital, Helsinki, Finland.
| | - Anna-Riia Holmström
- Division of Pharmacology and Pharmacotherapy, Faculty of Pharmacy, University of Helsinki, Viikinkaari 5 E, PL 56, 00014, Helsinki, Finland
| | - Eva Kunnola
- Division of Pharmacology and Pharmacotherapy, Faculty of Pharmacy, University of Helsinki, Viikinkaari 5 E, PL 56, 00014, Helsinki, Finland
| | - Sini Kuitunen
- HUS Pharmacy, Helsinki University Hospital, Helsinki, Finland
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Lawrence J, South M, Hiscock H, Capurro D, Sharma A, Ride J. Retrospective analysis of the impact of electronic medical record alerts on low value care in a pediatric hospital. J Am Med Inform Assoc 2024; 31:600-610. [PMID: 38078841 PMCID: PMC10873857 DOI: 10.1093/jamia/ocad239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 11/08/2023] [Accepted: 12/05/2023] [Indexed: 02/18/2024] Open
Abstract
OBJECTIVES Hospital costs continue to rise unsustainably. Up to 20% of care is wasteful including low value care (LVC). This study aimed to understand whether electronic medical record (EMR) alerts are effective at reducing pediatric LVC and measure the impact on hospital costs. MATERIALS AND METHODS Using EMR data over a 76-month period, we evaluated changes in 4 LVC practices following the implementation of EMR alerts, using time series analysis to control for underlying time-based trends, in a large pediatric hospital in Australia. The main outcome measure was the change in rate of each LVC practice. Balancing measures included the rate of alert adherence as a proxy measure for risk of alert fatigue. Hospital costs were calculated by the volume of LVC avoided multiplied by the unit costs. Costs of the intervention were calculated from clinician and analyst time required. RESULTS All 4 LVC practices showed a statistically significant reduction following alert implementation. Two LVC practices (blood tests) showed an abrupt change, associated with high rates of alert adherence. The other 2 LVC practices (bronchodilator use in bronchiolitis and electrocardiogram ordering for sleeping bradycardia) showed an accelerated rate of improvement compared to baseline trends with lower rates of alert adherence. Hospital savings were $325 to $180 000 per alert. DISCUSSION AND CONCLUSION EMR alerts are effective in reducing pediatric LVC practices and offer a cost-saving opportunity to the hospital. Further efforts to leverage EMR alerts in pediatric settings to reduce LVC are likely to support future sustainable healthcare delivery.
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Affiliation(s)
- Joanna Lawrence
- Electronic Medical Record Team, Royal Children’s Hospital, Melbourne 3052, Australia
- Health Services Group, Murdoch Children’s Research Institute, Melbourne 3052, Australia
- Department of Paediatrics, University of Melbourne, Melbourne 3052, Australia
- School of Population Health, Faculty of Medicine UNSW, Sydney 2052, Australia
- Centre for Digital Transformation of Health, University of Melbourne, Melbourne 3052, Australia
- Centre for Health Analytics, Melbourne Children’s Campus, Melbourne 3052, Australia
| | - Mike South
- Electronic Medical Record Team, Royal Children’s Hospital, Melbourne 3052, Australia
- Health Services Group, Murdoch Children’s Research Institute, Melbourne 3052, Australia
- Department of Paediatrics, University of Melbourne, Melbourne 3052, Australia
- Centre for Health Analytics, Melbourne Children’s Campus, Melbourne 3052, Australia
| | - Harriet Hiscock
- Health Services Group, Murdoch Children’s Research Institute, Melbourne 3052, Australia
- Department of Paediatrics, University of Melbourne, Melbourne 3052, Australia
| | - Daniel Capurro
- Centre for Digital Transformation of Health, University of Melbourne, Melbourne 3052, Australia
| | - Anurag Sharma
- School of Population Health, Faculty of Medicine UNSW, Sydney 2052, Australia
| | - Jemimah Ride
- Health Economics Group, School of Public Health and Preventive Medicine, Monash University, Melbourne 3800, Australia
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Ruan EL, Rossetti SC, Hsu H, Kim EY, Trepp RC. A Practical Approach to Optimize Computerized Provider Order Entry Systems and Reduce Clinician Burden: Pre-Post Evaluation of Vendor-Derived "Order Friction" Data. AMIA Annu Symp Proc 2024; 2023:1246-1256. [PMID: 38222358 PMCID: PMC10785931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
Computerized provider order entry (CPOE) systems have been cited as a significant contributor to clinician burden. Vendor-derived measures and data sets have been developed to help with optimization of CPOE systems. We describe how we analyzed vendor-derived Order Friction (OF) EHR log data at our health system and propose a practical approach for optimizing CPOE systems by reducing OF. We also conducted a pre-post intervention study using OF data to evaluate the impact of defaulting the frequency of urine, stool and nasal swab tests and found that all modified orders had significantly fewer changes required per order (p<0.01). Our proposed approach is a six-step process: 1) understand the ordering process, 2) understand OF data elements contextually, 3) explore ordering user-level factors, 4) evaluate order volume and friction from different order sources, 5) optimize order-level design, 6) identify high volume alerts to evaluate for appropriateness.
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Affiliation(s)
- Elise L Ruan
- Department of Biomedical Informatics, Columbia University, New York, New York, USA
- Department of Medicine, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - Sarah C Rossetti
- Department of Biomedical Informatics, Columbia University, New York, New York, USA
- School of Nursing, Columbia University, New York, New York, USA
| | - Hanson Hsu
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | - Eugene Y Kim
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Richard C Trepp
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
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11
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Kindler KE, Martinson PJ. Detecting atypical alert behavior through statistical process control: Clinical decision support alert frequency visualizations. Health Informatics J 2024; 30:14604582241234252. [PMID: 38366366 DOI: 10.1177/14604582241234252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
Clinical decision support (CDS) alerts are designed to work according to a set of clearly defined criteria and have the potential to improve clinical care. To efficiently and proactively review abnormally functioning CDS alerts, we postulate that the introduction of a dashboard with statistical process control (SPC) charting will lead to effective detection of erratic alert behavior. We identified custom CDS alerts from an academic medical center that were recorded and monitored in a longitudinal fashion and the data warehouses where this information was stored. We created a dashboard of alert frequency using SPC charts, applied SPC rules for classification of variation, and validated dashboard data. From June-August 2022, the dashboard effectively pulled in data to visually depict alert behavior. SPC-defined parameters for standard deviation from the mean were applied to visualizations and allowed for rapid review of alerts with greatest variation. These alerts were subsequently investigated, and it was determined that they were functioning correctly. The most profound abnormalities detected during implementation reflected changes in practice and not system errors, though further investigation into thresholds for statistical significance will benefit this field. We conclude that SPC visualizations are a time-efficient and effective method of identifying CDS malfunctions.
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12
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Fallon A, Haralambides K, Mazzillo J, Gleber C. Addressing Alert Fatigue by Replacing a Burdensome Interruptive Alert with Passive Clinical Decision Support. Appl Clin Inform 2024; 15:101-110. [PMID: 38086417 PMCID: PMC10830237 DOI: 10.1055/a-2226-8144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 12/11/2023] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND Recognizing that alert fatigue poses risks to patient safety and clinician wellness, there is a growing emphasis on evaluation and governance of electronic health record clinical decision support (CDS). This is particularly critical for interruptive alerts to ensure that they achieve desired clinical outcomes while minimizing the burden on clinicians. This study describes an improvement effort to address a problematic interruptive alert intended to notify clinicians about patients needing coronavirus disease 2019 (COVID) precautions and how we collaborated with operational leaders to develop an alternative passive CDS system in acute care areas. OBJECTIVES Our dual aim was to reduce the alert burden by redesigning the CDS to adhere to best practices for decision support while also improving the percent of admitted patients with symptoms of possible COVID who had appropriate and timely infection precautions orders. METHODS Iterative changes to CDS design included adjustment to alert triggers and acknowledgment reasons and development of a noninterruptive rule-based order panel for acute care areas. Data on alert burden and appropriate precautions orders on symptomatic admitted patients were followed over time on run and attribute (p) and individuals-moving range control charts. RESULTS At baseline, the COVID alert fired on average 8,206 times per week with an alert per encounter rate of 0.36. After our interventions, the alerts per week decreased to 1,449 and alerts per encounter to 0.07 equating to an 80% reduction for both metrics. Concurrently, the percentage of symptomatic admitted patients with COVID precautions ordered increased from 23 to 61% with a reduction in the mean time between COVID test and precautions orders from 19.7 to -1.3 minutes. CONCLUSION CDS governance, partnering with operational stakeholders, and iterative design led to successful replacement of a frequently firing interruptive alert with less burdensome passive CDS that improved timely ordering of COVID precautions.
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Affiliation(s)
- Anne Fallon
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Rochester Medical Center, Rochester, New York, United States
| | - Kristina Haralambides
- Department of Otolaryngology, University of Rochester Medical Center, Rochester, New York, United States
| | - Justin Mazzillo
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, United States
| | - Conrad Gleber
- Division of Hospital Medicine, Department of Medicine, University of Rochester Medical Center, Rochester, New York, United States
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13
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Hashemi S, Bai L, Gao S, Burstein F, Renzenbrink K. Sharpening clinical decision support alert and reminder designs with MINDSPACE: A systematic review. Int J Med Inform 2024; 181:105276. [PMID: 37948981 DOI: 10.1016/j.ijmedinf.2023.105276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/07/2023] [Accepted: 10/28/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Clinical decision support (CDS) alerts and reminders aim to influence clinical decisions, yet they are often designed without considering human decision-making behaviour. While this behaviour is comprehensively described by behavioural economics (BE), the sheer volume of BE literature poses a challenge to designers when identifying behavioural effects with utility to alert and reminder designs. This study tackles this challenge by focusing on the MINDSPACE framework for behaviour change, which collates nine behavioural effects that profoundly influence human decision-making behaviour: Messenger, Incentives, Norms, Defaults, Salience, Priming, Affect, Commitment, and Ego. METHOD A systematic review searching MEDLINE, Embase, PsycINFO, and CINAHL Plus to explore (i) the usage of MINDSPACE effects in alert and reminder designs and (ii) the efficacy of those alerts and reminders in influencing clinical decisions. The search queries comprised ten Boolean searches, with nine focusing on the MINDSPACE effects and one focusing on the term mindspace. RESULTS 50 studies were selected from 1791 peer-reviewed journal articles in English from 1970 to 2022. Except for ego, eight of nine MINDSPACE effects were utilised to design alerts and reminders, with defaults and norms utilised the most in alerts and reminders, respectively. Overall, alerts and reminders informed by MINDSPACE effects showed an average 71% success rate in influencing clinical decisions (alerts 73%, reminders 69%). Most studies utilised a single effect in their design, with higher efficacy for alerts (64%) than reminders (41%). Others utilised multiple effects, showing higher efficacy for reminders (28%) than alerts (9%). CONCLUSION This review presents sufficient evidence demonstrating the MINDSPACE framework's merits for designing CDS alerts and reminders with human decision-making considerations. The framework can adequately address challenges in identifying behavioural effects pertinent to the effective design of CDS alerts and reminders. The review also identified opportunities for future research into other relevant effects (e.g., framing).
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Affiliation(s)
- Sarang Hashemi
- Department of Human-Centred Computing, Faculty of Information Technology, Monash University, Melbourne, VIC, Australia.
| | - Lu Bai
- Department of Human-Centred Computing, Faculty of Information Technology, Monash University, Melbourne, VIC, Australia
| | - Shijia Gao
- Department of Human-Centred Computing, Faculty of Information Technology, Monash University, Melbourne, VIC, Australia
| | - Frada Burstein
- Department of Human-Centred Computing, Faculty of Information Technology, Monash University, Melbourne, VIC, Australia
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14
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Chen CY, Chen YL, Scholl J, Yang HC, Li YCJ. Ability of machine-learning based clinical decision support system to reduce alert fatigue, wrong-drug errors, and alert users about look alike, sound alike medication. Comput Methods Programs Biomed 2024; 243:107869. [PMID: 37924770 DOI: 10.1016/j.cmpb.2023.107869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 09/08/2023] [Accepted: 10/15/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND AND OBJECTIVE The overall benefits of using clinical decision support systems (CDSSs) can be restrained if physicians inadvertently ignore clinically useful alerts due to "alert fatigue" caused by an excessive number of clinically irrelevant warnings. Moreover, inappropriate drug errors, look-alike/sound-alike (LASA) drug errors, and problem list documentation are common, costly, and potentially harmful. This study sought to evaluate the overall performance of a machine learning-based CDSS (MedGuard) for triggering clinically relevant alerts, acceptance rate, and to intercept inappropriate drug errors as well as LASA drug errors. METHODS We conducted a retrospective study that evaluated MedGuard alerts, the alert acceptance rate, and the rate of LASA alerts between July 1, 2019, and June 31, 2021, from outpatient settings at an academic hospital. An expert pharmacist checked the suitability of the alerts, rate of acceptance, wrong-drug errors, and confusing drug pairs. RESULTS Over the two-year study period, 1,206,895 prescriptions were ordered and a total of 28,536 alerts were triggered (alert rate: 2.36 %). Of the 28,536 alerts presented to physicians, 13,947 (48.88 %) were accepted. A total of 8,014 prescriptions were changed/modified (28.08 %, 8,014/28,534) with the most common reasons being adding and/or deleting diseases (52.04 %, 4,171/8,014), adding and/or deleting drugs (21.89 %, 1,755/8,014) and others (35.48 %, 2,844/ 8,014). However, the rate of drug error interception was 1.64 % (470 intercepted errors out of 28,536 alerts), which equates to 16.4 intercepted errors per 1000 alerted orders. CONCLUSION This study shows that machine learning based CDSS, MedGuard, has an ability to improve patients' safety by triggering clinically valid alerts. This system can also help improve problem list documentation and intercept inappropriate drug errors and LASA drug errors, which can improve medication safety. Moreover, high acceptance of alert rates can help reduce clinician burnout and adverse events.
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Affiliation(s)
- Chun-You Chen
- College of Medical Science and Technology, Graduate Institute of Biomedical Informatics, Taipei Medical University, Taipei, Taiwan; Department of Radiation Oncology, Taipei Municipal Wan Fang Hospital, Taipei 110, Taiwan; Information Technology Office in Taipei Municipal Wan Fang Hospital, Taipei Medical University, Taipei 110, Taiwan; Artificial Intelligence Research and Development Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Ya-Lin Chen
- College of Medical Science and Technology, Graduate Institute of Biomedical Informatics, Taipei Medical University, Taipei, Taiwan; Department of Biomedical Informatics and Medical Education, University of Washington, United States
| | | | - Hsuan-Chia Yang
- College of Medical Science and Technology, Graduate Institute of Biomedical Informatics, Taipei Medical University, Taipei, Taiwan; International Center for Health Information Technology (ICHIT), Taipei Medical University, Taipei, Taiwan; Clinical Big Data Research Center, Taipei Medical University Hospital, Taipei, Taiwan; Research Center of Big Data and Meta-analysis, Wanfang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yu-Chuan Jack Li
- College of Medical Science and Technology, Graduate Institute of Biomedical Informatics, Taipei Medical University, Taipei, Taiwan; International Center for Health Information Technology (ICHIT), Taipei Medical University, Taipei, Taiwan; Research Center of Big Data and Meta-analysis, Wanfang Hospital, Taipei Medical University, Taipei, Taiwan; Department of Dermatology, Wanfang Hospital, Taipei Medical University, Taiwan.
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15
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Nezu M, Sakuma M, Nakamura T, Sonoyama T, Matsumoto C, Takeuchi J, Ohta Y, Kosaka S, Morimoto T. Monitoring for adverse drug events of high-risk medications with a computerized clinical decision support system: a prospective cohort study. Int J Qual Health Care 2023; 35:mzad095. [PMID: 37982724 DOI: 10.1093/intqhc/mzad095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 10/16/2023] [Accepted: 11/19/2023] [Indexed: 11/21/2023] Open
Abstract
Monitoring is recommended to prevent severe adverse drug events, but such examinations are often missed. To increase the number of monitoring that should be ordered for high-risk medications, we introduced a clinical decision support system (CDSS) that alerts and orders the monitoring for high-risk medications in an outpatient setting. We conducted a 2-year prospective cohort study at a tertiary care teaching hospital before (phase 1) and after (phase 2) the activation of a CDSS. The CDSS automatically provided alerts for liver function tests for vildagliptin, thyroid function tests for immune checkpoint inhibitors (ICIs) and multikinase inhibitors (MKIs), and a slit-lamp examination of the eyes for oral amiodarone when outpatients were prescribed the medications but not examined for a fixed period. The order of laboratory tests automatically appeared if alert was accepted. The alerts were hidden and did not appear on the display before activation of the CDSS. The outcomes were the number of prescriptions with alerts and examinations. During the study period, 330 patients in phase 1 and 307 patients in phase 2 were prescribed vildagliptin, 20 patients in phase 1 and 19 patients in phase 2 were prescribed ICIs or MKIs, and 72 patients in phase 1 and 66 patients in phase 2 were prescribed oral amiodarone. The baseline characteristics were similar between the phases. In patients prescribed vildagliptin, the proportion of alerts decreased significantly (38% vs 27%, P < 0.0001), and the proportion of examinations increased significantly (0.9% vs 4.0%, P < 0.0001) after activation of the CDSS. In patients prescribed ICIs or MKIs, the proportion of alerts decreased significantly (43% vs 11%, P < 0.0001), and the proportion of examinations increased numerically, but not significantly (2.6% vs 7.0%, P = 0.13). In patients prescribed oral amiodarone, the proportion of alerts decreased (86% vs 81%, P = 0.055), and the proportion of examinations increased (2.2% and 3.0%, P = 0.47); neither was significant. The CDSS has potential to increase the monitoring for high-risk medications. Our study also highlighted the limited acceptance rate of monitoring by CDSS. Further studies are needed to explore the generalizability to other medications and the cause of the limited acceptance rates among physicians.
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Affiliation(s)
- Mari Nezu
- Department of Clinical Epidemiology, Hyogo Medical University, 1-1 Mukogawa, Nishinomiya 663-8501, Japan
| | - Mio Sakuma
- Department of Clinical Epidemiology, Hyogo Medical University, 1-1 Mukogawa, Nishinomiya 663-8501, Japan
| | - Tsukasa Nakamura
- Department of Infectious Diseases, Shimane Prefectural Central Hospital, 4-1-1 Himebara, Izumo 693-8555, Japan
| | - Tomohiro Sonoyama
- Department of Pharmacy, Shimane Prefectural Central Hospital, 4-1-1 Himebara, Izumo 693-8555, Japan
| | - Chisa Matsumoto
- Center for Health Surveillance and Preventive Medicine, Tokyo Medical University, 6-1-1 Shinjuku, Shinjuku 160-8402, Japan
| | - Jiro Takeuchi
- Department of Clinical Epidemiology, Hyogo Medical University, 1-1 Mukogawa, Nishinomiya 663-8501, Japan
| | - Yoshinori Ohta
- Department of Clinical Epidemiology, Hyogo Medical University, 1-1 Mukogawa, Nishinomiya 663-8501, Japan
| | - Shinji Kosaka
- Shimane Prefectural Central Hospital, 4-1-1 Himebara, Izumo 693-8555, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo Medical University, 1-1 Mukogawa, Nishinomiya 663-8501, Japan
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16
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Lemke LK, Cicali EJ, Williams R, Nguyen KA, Cavallari LH, Wiisanen K. Clinician Response to Pharmacogenetic Clinical Decision Support Alerts. Clin Pharmacol Ther 2023; 114:1350-1357. [PMID: 37716912 PMCID: PMC10726431 DOI: 10.1002/cpt.3051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 08/09/2023] [Indexed: 09/18/2023]
Abstract
The objective of this study was to characterize clinician response following standardization of pharmacogenetic (PGx) clinical decision support alerts at University of Florida (UF) Health. A retrospective analysis of all PGx alerts that fired at a tertiary academic medical center from August 2020 through May 2022 was performed. Alert acceptance rate was calculated and compared across six gene-drug pairs, patient care setting, and clinician specialty. The disposition of the triggering medication was compared with the alert response and evaluated for congruence. There were a total of 818 alerts included for analysis of alert response, 557 alerts included in acceptance rate calculations, and 392 alerts with sufficient information to assess clinical response. The overall acceptance rate was 63%. The alert response and clinical response were congruent for 47% of alerts. Alert response was influenced by the triggering gene-drug pair, clinician specialty, patient care setting, and specialty of the provider who initially ordered the PGx test. Clinical response was mostly incongruent with alert response. Alert acceptance is influenced by the triggering gene-drug pair, clinician specialty, and care setting. Alert response is not a reliable surrogate marker for clinical action. Any future research into the impact of clinical decision support (CDS) alerts should focus on clinical response rather than alert response. Given the reliance on CDS alerts to enhance uptake of PGx, it is worthwhile to further investigate their impact on prescribing and patient outcomes.
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Affiliation(s)
- Lauren K Lemke
- Pharmacotherapy and Translational Research, University of Florida, Gainesville, USA
| | - Emily J Cicali
- Pharmacotherapy and Translational Research, University of Florida, Gainesville, USA
| | - Roy Williams
- Pharmacotherapy and Translational Research, University of Florida, Gainesville, USA
| | - Khoa A Nguyen
- Pharmacotherapy and Translational Research, University of Florida, Gainesville, USA
| | - Larisa H Cavallari
- Pharmacotherapy and Translational Research, University of Florida, Gainesville, USA
| | - Kristin Wiisanen
- Pharmacotherapy and Translational Research, University of Florida, Gainesville, USA
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17
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Jung W, Yu J, Park H, Chae MK, Lee SS, Choi JS, Kang M, Chang DK, Cha WC. Effect of knowledgebase transition of a clinical decision support system on medication order and alert patterns in an emergency department. Sci Rep 2023; 13:21206. [PMID: 38040729 PMCID: PMC10692153 DOI: 10.1038/s41598-023-40188-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 08/06/2023] [Indexed: 12/03/2023] Open
Abstract
A knowledgebase (KB) transition of a clinical decision support (CDS) system occurred at the study site. The transition was made from one commercial database to another, provided by a different vendor. The change was applied to all medications in the institute. The aim of this study was to analyze the effect of KB transition on medication-related orders and alert patterns in an emergency department (ED). Data of patients, medication-related orders and alerts, and physicians in the ED from January 2018 to December 2020 were analyzed in this study. A set of definitions was set to define orders, alerts, and alert overrides. Changes in order and alert patterns before and after the conversion, which took place in May 2019, were assessed. Overall, 101,450 patients visited the ED, and 1325 physicians made 829,474 prescription orders to patients during visit and at discharge. Alert rates (alert count divided by order count) for periods A and B were 12.6% and 14.1%, and override rates (alert override count divided by alert count) were 60.8% and 67.4%, respectively. Of the 296 drugs that were used more than 100 times during each period, 64.5% of the drugs had an increase in alert rate after the transition. Changes in alert rates were tested using chi-squared test and Fisher's exact test. We found that the CDS system knowledgebase transition was associated with a significant change in alert patterns at the medication level in the ED. Careful consideration is advised when such a transition is performed.
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Affiliation(s)
- Weon Jung
- Department of Digital Health, Samsung Advanced Institute of Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, 06351, Korea
| | - Jaeyong Yu
- Department of Digital Health, Samsung Advanced Institute of Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, 06351, Korea
| | - Hyunjung Park
- Department of Digital Health, Samsung Advanced Institute of Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, 06351, Korea
| | - Minjung Kathy Chae
- Department of Digital Health, Samsung Advanced Institute of Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, 06351, Korea
| | - Sang Seob Lee
- Digital Innovation Center, Samsung Medical Center, Seoul, 06351, Korea
| | - Jong Soo Choi
- Department of Digital Health, Samsung Advanced Institute of Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, 06351, Korea
- Digital Innovation Center, Samsung Medical Center, Seoul, 06351, Korea
| | - Mira Kang
- Department of Digital Health, Samsung Advanced Institute of Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, 06351, Korea
- Digital Innovation Center, Samsung Medical Center, Seoul, 06351, Korea
- Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Korea
| | - Dong Kyung Chang
- Department of Digital Health, Samsung Advanced Institute of Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, 06351, Korea
- Digital Innovation Center, Samsung Medical Center, Seoul, 06351, Korea
- Department of Gastroenterology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351, Korea
| | - Won Chul Cha
- Department of Digital Health, Samsung Advanced Institute of Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, 06351, Korea.
- Digital Innovation Center, Samsung Medical Center, Seoul, 06351, Korea.
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-Ro, Gangnam-Gu, Seoul, 06351, Korea.
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18
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Mattay GS, Griffey RT, Narra V, Poirier RF, Bierhals A. Impact of Predictive Text Clinical Decision Support on Imaging Order Entry in the Emergency Department. J Am Coll Radiol 2023; 20:1250-1257. [PMID: 37805010 DOI: 10.1016/j.jacr.2023.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/03/2023] [Accepted: 05/09/2023] [Indexed: 10/09/2023]
Abstract
PURPOSE Imaging clinical decision support (CDS) is designed to assist providers in selecting appropriate imaging studies and is now federally required. The aim of this study was to understand the effect of CDS on decisions and workflows in the emergency department (ED). METHODS The authors' institution's order entry platform serves up structured indications for imaging orders. Imaging orders are scored by CDS on the basis of appropriate use criteria (AUC). CDS triggers alerts for imaging orders with low AUC scores. Because free text alone cannot be scored by CDS, an artificial intelligence predictive text (AIPT) module was implemented to guide the selection of structured indications when free-text indications are entered. A total of 17,355 imaging orders in the ED over 6 months were retrospectively analyzed. RESULTS CDS alerts for low AUC scores were triggered for 3% of all imaging study orders (522 of 17,355). Providers spent an average of 24 seconds interacting with alerts. In 18 of 522 imaging orders with alerts, alternative studies were ordered. After AIPT implementation, the percentage of unscored studies significantly decreased from 81% to 45% (P < .001). CONCLUSIONS In a quaternary academic ED, CDS alerts triggered by low AUC scores caused minimal increase in time spent on imaging order entry but had a relatively marginal impact on imaging study selection. AIPT implementation increased the number of scored studies and could potentially enhance CDS effects. CDS implementation enables the collection of novel data regarding which imaging studies receive low AUC scores. Future work could include exploring alternative models of CDS implementation to maximize its impact.
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Affiliation(s)
- Govind S Mattay
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri.
| | - Richard T Griffey
- Associate Chief, Emergency Medicine, Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Vamsi Narra
- Senior Vice Chair, Imaging Informatics and New Business Development, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri; Chief, Radiology, Barnes-Jewish West County Hospital, St. Louis, Missouri; Associate Chief Medical Informatics Officer, BJC HealthCare, St. Louis, Missouri
| | - Robert F Poirier
- Associate Chief, Emergency Medicine, Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri; Medical Director and Chief of Clinical Operations, Emergency Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Andrew Bierhals
- Vice Chair, Community Radiology, Vice Chair, Quality and Safety, Medical and Director for CT, Center for Clinical Imaging Research, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri; Director of Cardiothoracic Imaging, Barnes-Jewish West County Hospital, St. Louis, Missouri. https://twitter.com/AMdmph
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19
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Nafees A, Khan M, Chow R, Fazelzad R, Hope A, Liu G, Letourneau D, Raman S. Evaluation of clinical decision support systems in oncology: An updated systematic review. Crit Rev Oncol Hematol 2023; 192:104143. [PMID: 37742884 DOI: 10.1016/j.critrevonc.2023.104143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 09/17/2023] [Accepted: 09/21/2023] [Indexed: 09/26/2023] Open
Abstract
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.
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Affiliation(s)
- Abdulwadud Nafees
- Radiation Medicine Program, Princess Margaret Hospital Cancer Centre, Toronto, Canada
| | - Maha Khan
- Radiation Medicine Program, Princess Margaret Hospital Cancer Centre, Toronto, Canada
| | - Ronald Chow
- Radiation Medicine Program, Princess Margaret Hospital Cancer Centre, Toronto, Canada; Institute of Biomedical Engineering, Faculty of Applied Sciences & Engineering, University of Toronto, Toronto, Canada; Library and Information Services, Princess Margaret Cancer Centre, Toronto, Canada
| | - Rouhi Fazelzad
- Institute of Biomedical Engineering, Faculty of Applied Sciences & Engineering, University of Toronto, Toronto, Canada; Library and Information Services, Princess Margaret Cancer Centre, Toronto, Canada
| | - Andrew Hope
- Radiation Medicine Program, Princess Margaret Hospital Cancer Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Geoffrey Liu
- Department of Medical Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Daniel Letourneau
- Radiation Medicine Program, Princess Margaret Hospital Cancer Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Srinivas Raman
- Radiation Medicine Program, Princess Margaret Hospital Cancer Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada.
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Shreve LA, Fried JG, Liu F, Cao Q, Pakpoor J, Kahn CE, Zafar HM. Impact of Artificial Intelligence-Assisted Indication Selection on Appropriateness Order Scoring for Imaging Clinical Decision Support. J Am Coll Radiol 2023; 20:1258-1266. [PMID: 37390881 DOI: 10.1016/j.jacr.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/20/2023] [Accepted: 04/06/2023] [Indexed: 07/02/2023]
Abstract
PURPOSE The aim of this study was to assess appropriateness scoring and structured order entry after the implementation of an artificial intelligence (AI) tool for analysis of free-text indications. METHODS Advanced outpatient imaging orders in a multicenter health care system were recorded 7 months before (March 1, 2020, to September 21, 2020) and after (October 20, 2020, to May 13, 2021) the implementation of an AI tool targeting free-text indications. Clinical decision support score (not appropriate, may be appropriate, appropriate, or unscored) and indication type (structured, free-text, both, or none) were assessed. The χ2 and multivariate logistic regression adjusting for covariables with bootstrapping were used. RESULTS In total, 115,079 orders before and 150,950 orders after AI tool deployment were analyzed. The mean patient age was 59.3 ± 15.5 years, and 146,035 (54.9%) were women; 49.9% of orders were for CT, 38.8% for MR, 5.9% for nuclear medicine, and 5.4% for PET. After deployment, scored orders increased to 52% from 30% (P < .001). Orders with structured indications increased to 67.3% from 34.6% (P < .001). On multivariate analysis, orders were more likely to be scored after tool deployment (odds ratio [OR], 2.7, 95% CI, 2.63-2.78; P < .001). Compared with physicians, orders placed by nonphysician providers were less likely to be scored (OR, 0.80; 95% CI, 0.78-0.83; P < .001). MR (OR, 0.84; 95% CI, 0.82-0.87) and PET (OR, 0.12; 95% CI, 0.10-0.13) were less likely to be scored than CT (; P < .001). After AI tool deployment, 72,083 orders (47.8%) remained unscored, 45,186 (62.7%) with free-text-only indications. CONCLUSIONS Embedding AI assistance within imaging clinical decision support was associated with increased structured indication orders and independently predicted a higher likelihood of scored orders. However, 48% of orders remained unscored, driven by both provider behavior and infrastructure-related barriers.
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Affiliation(s)
- Lauren A Shreve
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Jessica G Fried
- Program Director, Abdominal Imaging, Associate Medical Director of Radiology Informatics, and Co-Director, Tumor Response Assessment Core, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Fang Liu
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Quy Cao
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jina Pakpoor
- Centre for Medical Imaging, University College London, London, United Kingdom
| | - Charles E Kahn
- Vice Chair, Department of Radiology, and Vice Chair of Informatics, Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania; Institute for Biomedical Informatics, University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hanna M Zafar
- Vice Chair of Quality, Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
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Ledger TS, Brooke-Cowden K, Coiera E. Post-implementation optimization of medication alerts in hospital computerized provider order entry systems: a scoping review. J Am Med Inform Assoc 2023; 30:2064-2071. [PMID: 37812769 PMCID: PMC10654862 DOI: 10.1093/jamia/ocad193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/07/2023] [Accepted: 09/18/2023] [Indexed: 10/11/2023] Open
Abstract
OBJECTIVES A scoping review identified interventions for optimizing hospital medication alerts post-implementation, and characterized the methods used, the populations studied, and any effects of optimization. MATERIALS AND METHODS A structured search was undertaken in the MEDLINE and Embase databases, from inception to August 2023. Articles providing sufficient information to determine whether an intervention was conducted to optimize alerts were included in the analysis. Snowball analysis was conducted to identify additional studies. RESULTS Sixteen studies were identified. Most were based in the United States and used a wide range of clinical software. Many studies used inpatient cohorts and conducted more than one intervention during the trial period. Alert types studied included drug-drug interactions, drug dosage alerts, and drug allergy alerts. Six types of interventions were identified: alert inactivation, alert severity reclassification, information provision, use of contextual information, threshold adjustment, and encounter suppression. The majority of interventions decreased alert quantity and enhanced alert acceptance. Alert quantity decreased with alert inactivation by 1%-25.3%, and with alert severity reclassification by 1%-16.5% in 6 of 7 studies. Alert severity reclassification increased alert acceptance by 4.2%-50.2% and was associated with a 100% acceptance rate for high-severity alerts when implemented. Clinical errors reported in 4 studies were seen to remain stable or decrease. DISCUSSION Post-implementation medication optimization interventions have positive effects for clinicians when applied in a variety of settings. Less well reported are the impacts of these interventions on the clinical care of patients, and how endpoints such as alert quantity contribute to changes in clinician and pharmacist perceptions of alert fatigue. CONCLUSION Well conducted alert optimization can reduce alert fatigue by reducing overall alert quantity, improving clinical acceptance, and enhancing clinical utility.
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Affiliation(s)
| | - Kalissa Brooke-Cowden
- Centre for Health Informatics, Australian Institute of Health Innovation, Macquarie University, NSW 2109, Australia
| | - Enrico Coiera
- Centre for Health Informatics, Australian Institute of Health Innovation, Macquarie University, NSW 2109, Australia
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Joshi RN, Kalaminsky S, Feemster AA, Hill J, Leiman J, Evelyn D, Duncan R. A Data-Driven Approach to Evaluate Barcode-Assisted Medication Preparation Alerts at a Large Academic Medical Center. Jt Comm J Qual Patient Saf 2023; 49:599-603. [PMID: 37429757 DOI: 10.1016/j.jcjq.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 06/12/2023] [Accepted: 06/19/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND The purpose of this study was to develop a data-driven process to analyze barcode-assisted medication preparation alert data with a goal of minimizing inaccurate alerts. METHODS Medication preparation data for the prior three-month period was obtained from an electronic health record system. A dashboard was developed to identify recurrent, high-volume alerts and associated medication records. A randomization tool was used to obtain a prespecified proportion of the alerts to review for appropriateness. Alert root causes were identified by chart review. Depending on the alert's cause(s), targeted informatics build changes, workflow and purchasing changes, and/or staff education were implemented. The rate of alerts was measured postintervention for select drugs. RESULTS The institution averaged 31,000 medication preparation alerts per month. The "barcode not recognized" alert (13,000) was the highest volume over the study period. Eighty-five medication records were identified as contributing to a high volume of alerts (5,200/31,000), representing 49 unique drugs. Of the 85 medication records triggering alerts, 36 required staff education, 22 required informatics build changes, and 8 required workflow changes. Targeted interventions for 2 medications, resulted in reducing the rate of the "barcode not recognized" alert from 26.6% to 1.3% for polyethylene glycol and from 48.7% to 0% for cyproheptadine. CONCLUSION This quality improvement project highlighted opportunities to improve medication purchasing, storage, and preparation through development of a standard process to evaluate barcode-assisted medication preparation alert data. A data-driven approach can help identify and minimize inaccurate alerts ("noise") and promote medication safety.
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Colicchio TK, Cimino JJ. Beyond the override: Using evidence of previous drug tolerance to suppress drug allergy alerts; a retrospective study of opioid alerts. J Biomed Inform 2023; 147:104508. [PMID: 37748541 DOI: 10.1016/j.jbi.2023.104508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 08/29/2023] [Accepted: 09/22/2023] [Indexed: 09/27/2023]
Abstract
OBJECTIVE Despite the extensive literature exploring alert fatigue, most studies have focused on describing the phenomenon, but not on fixing it. The authors aimed to identify data useful to avert clinically irrelevant alerts to inform future research on clinical decision support (CDS) design. METHODS We conducted a retrospective observational study of opioid drug allergy alert (DAA) overrides for the calendar year of 2019 at a large academic medical center, to identify data elements useful to find irrelevant alerts to be averted. RESULTS Overall, 227,815 DAAs were fired in 2019, with an override rate of 91 % (n = 208196). Opioids represented nearly two-thirds of these overrides (n = 129063; 62 %) and were the drug class with the highest override rate (96 %). On average, 29 opioid DAAs were overridden per patient. While most opioid alerts (97.1 %) are fired for a possible match (the drug class of the allergen matches the drug class of the prescribed drug), they are overridden significantly less frequently for definite match (exact match between allergen and prescribed drug) (88 % vs. 95.9 %, p < 0.001). When comparing the triggering drug with previously administered drugs, override rates were equally high for both definite match (95.9 %), no match (95.5 %), and possible match (95.1 %). Likewise, when comparing to home medications, overrides were excessively high for possible match (96.3 %), no match (96 %), and definite match (94.4 %). CONCLUSION We estimate that 74.5% of opioid DAAs (46.4% of all DAAs) at our institution could be relatively safely averted, since they either have a definite match for previous inpatient administrations suggesting drug tolerance or are fired as possible match with low risk of cross-sensitivity. Future research should focus on identifying other relevant data elements ideally with automated methods and use of emerging standards to empower CDS systems to suppress false-positive alerts while avoiding safety hazards.
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Affiliation(s)
- Tiago K Colicchio
- Informatics Institute, University of Alabama at Birmingham, AL, USA.
| | - James J Cimino
- Informatics Institute, University of Alabama at Birmingham, AL, USA
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Montazeri M, Khajouei R, Afraz A, Ahmadian L. A systematic review of data elements of computerized physician order entry (CPOE): mapping the data to FHIR. Inform Health Soc Care 2023; 48:402-419. [PMID: 37723918 DOI: 10.1080/17538157.2023.2255285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Abstract
OBJECTIVE Medication errors are the third leading cause of death. There are several methods to prevent prescription errors, one of which is to use a Computerized Physician Order Entry system (CPOE). In a CPOE system, necessary data needs to be collected so that making decisions about prescribing medications and treatment plans could be made. Although many CPOE systems have been developed worldwide, studies have yet to identify the necessary data and data elements of CPOE systems. This study aims to identify data elements of CPOE and standardize these data with Fast Healthcare Interoperability Resources (FHIR) to facilitate data sharing and integration with the electronic health record (EHR) system and reduce data diversity. METHODS PubMed, Web of Science, Embase, and Scopus databases for studies up to October 2019 were searched. Two reviewers independently assessed original articles to determine eligibility for inclusion in this review. All articles describing data elements of a COPE system were included. Data elements were obtained from the included articles' text, tables, and figures.Classification of the extracted data elements and mapping them to FHIR was done to facilitate data sharing and integration with the electronic health record (EHR) system and reduce data diversity. The final data elements of CPOE were categorized into five main categories of FHIR (foundation, base, clinical, financial, and specialized) and 146 resources, where possible. One of the researchers did mapping and checked and verified by the second researcher. If a data element could not be mapped to any FHIR resources, this data element was considered an extension to the most relevant resource. RESULTS We retrieved 5162 articles through database searches. After the full-text assessment, 21 articles were included. In total, 270 data elements were identified and mapped to the FHIR standard. These elements have been reported in 26 FHIR resources of 146 ones (18%). In total, 71 data elements were considered an extension. CONCLUSIONS The results of this study showed that the same data elements were not used in the CPOE systems, and the degree of homogeneity of these systems is limited. The mapping of extracted data with data elements used in the FHIR standard shows the extent to which these systems comply with existing standards. Considering the standards in these systems' design helps developers design more coherent systems that can share data with other systems.
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Affiliation(s)
- Mahdieh Montazeri
- Medical Informatics Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
- Department of Health Information Sciences, Faculty of Management and Medical Information Sciences, Kerman University of Medical Sciences, Kerman, Iran
| | - Reza Khajouei
- Department of Health Information Sciences, Faculty of Management and Medical Information Sciences, Kerman University of Medical Sciences, Kerman, Iran
| | - Ali Afraz
- Medical Informatics Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Leila Ahmadian
- Medical Informatics Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
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Kannry J. Alert acceptance: are all acceptance rates the same? J Am Med Inform Assoc 2023; 30:1754. [PMID: 37535817 PMCID: PMC10531185 DOI: 10.1093/jamia/ocad151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 07/27/2023] [Indexed: 08/05/2023] Open
Affiliation(s)
- Joseph Kannry
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Karajizadeh M, Zand F, Vazin A, Saeidnia HR, Lund BD, Tummuru SP, Sharifian R. Design, development, implementation, and evaluation of a severe drug-drug interaction alert system in the ICU: An analysis of acceptance and override rates. Int J Med Inform 2023; 177:105135. [PMID: 37406570 DOI: 10.1016/j.ijmedinf.2023.105135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 06/10/2023] [Accepted: 06/22/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND AND OBJECTIVE The override rate of Drug-Drug Interaction Alerts (DDIA) in Intensive Care Units (ICUs) is very high. Therefore, this study aimed to design, develop, implement, and evaluate a severe Drug-Drug Alert System (DDIAS) in a system of ICUs and measure the override rate of this system. METHODS This is a cross-sectional study that details the design, development, implementation, and evaluation of a DDIAS for severe interactions into a Computerized Provider Order Entry (CPOE) system in the ICUs of Nemazee general teaching hospitals in 2021. The patients exposed to the volume of DDIAS, acceptance and overridden of DDIAS, and usability of DDIAS have been collected. The study was approved by the local Institutional Review Board (IRB) and; the ethics committee of Shiraz University of Medical Science on date: 2019-11-23 (Approval ID: IR.SUMS.REC.1398.1046). RESULTS The knowledge base of the DDIAS contains 9,809 severe potential drug-drug interactions (pDDIs). A total of 2672 medications were prescribed in the population study. The volume and acceptance rate for the DDIAS were 81 % and 97.5 %, respectively. The override rate was 2.5 %. The mean System Usability Scale (SUS) score of the DDIAS was 75. CONCLUSION This study demonstrates that implementing high-risk DDIAS at the point of prescribing in ICUs improves adherence to alerts. In addition, the usability of the DDIAS was reasonable. Further studies are needed to investigate the establishment of severe DDIAS and measure the prescribers' response to DDIAS on a larger scale.
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Affiliation(s)
- Mehrdad Karajizadeh
- Shiraz University of Medical, Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz, Iran.
| | - Farid Zand
- Shiraz University of Medical Sciences, Anesthesiology and Critical Care Research Center, Shiraz, Iran
| | - Afsaneh Vazin
- Shiraz University of Medical Sciences, Shiraz, Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz, Iran
| | | | - Brady D Lund
- University of North Texas, Department of Information Science, Denton, TX, US
| | - Sai Priya Tummuru
- University of North Texas, Department of Information Science, Denton, TX, US
| | - Roxana Sharifian
- Shiraz University of Medical Sciences, Department of Health Information Management, Health Human Resources Research Center, School of Management & Medical Information Sciences, Shiraz, Iran.
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Rosado-Ingelmo A, Pastor Magro AB, Pizarro-Jaraiz MA, Sanz-Marquez S, Silva Riádigos GM, Peña Acevedo Y, Tejedor-Alberti A, Tejedor-Alonso MA. Drug Allergy Alert System in a Spanish University Hospital: Description and Dynamics of Use. Int Arch Allergy Immunol 2023; 184:1079-1089. [PMID: 37598675 DOI: 10.1159/000531170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/17/2023] [Indexed: 08/22/2023] Open
Abstract
INTRODUCTION The drug allergy alert system reduces the frequency of adverse drug events, although it is subjected to collateral effects, since 80-90% of alerts are not real, and a large percentage of alerts are overridden (46.2-96.2%). We reviewed how the alert system is used at University Hospital Fundación Alcorcon (HUFA). METHODS Data were obtained from the drug allergy alert and the alert overriding notification forms (both in the period 2011-20). We also recorded drug allergy diagnoses at HUFA, drug consumption in primary care in 2016. We calculated the incidence of drug allergy alert activation, temporal trends in use, and correlations between the number of drugs in several datasets. RESULTS We collected 15,535 alerts. NSAIDs and penicillins were the drugs with the highest number of drug allergy alerts (36.55% and 26.91%, respectively). A correlation was found between the number of drug alerts and the type of drug allergy in HUFA in 2016. Only 6.83% of the alerts were removed, and, of these, 21.77% were reactivated. Approximately 100 overrides were recorded per year from 2016 (6.8% of 8,434 activated alerts during 2014-2020). CONCLUSIONS The number of drug allergy alerts recorded via the drug allergy alert system of HUFA correlates with the distribution of drug allergy diagnoses in the hospital, although many of the alerts could be false positives (as per current published evidence). We detected a very low frequency of removed alerts (6.83%), a relevant frequency of reactivations (one quarter), and a very low frequency of overrides (6.8%).
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Affiliation(s)
- Ana Rosado-Ingelmo
- Allergy Unit, University Hospital Fundación Alcorcón, Alcorcón, Spain
- International Doctoral School, Faculty of Health Sciences (Ciencias de la Salud), University Rey Juan Carlos, Alcorcón, Spain
| | - Ana Belen Pastor Magro
- Systems and Information Technologies, University Hospital Fundación Alcorcón, Alcorcón, Spain
| | | | - Sira Sanz-Marquez
- Pharmacy Area, University Hospital Fundacion Alcorcón, Alcorcón, Spain
| | - Genma M Silva Riádigos
- Pharmacy Department, Primary Care Management, Madrid Health Service (SERMAS)., Móstoles, Spain
| | - Yesenia Peña Acevedo
- Allergy Section, University Hospital General de Lanzarote, Doctor José Molina Orosa, Arrecife, Spain
| | | | - Miguel Angel Tejedor-Alonso
- Allergy Unit, University Hospital Fundación Alcorcón, Alcorcón, Spain
- Department of Public Health and Medical Specialties, Faculty of Health Sciencies (Facultad Ciencias de la Salud), University Rey Juan Carlos, Alcorcón, Spain
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Zhang T, Gephart SM, Subbian V, Boyce RD, Villa-Zapata L, Tan MS, Horn J, Gomez-Lumbreras A, Romero AV, Malone DC. Barriers to Adoption of Tailored Drug-Drug Interaction Clinical Decision Support. Appl Clin Inform 2023; 14:779-788. [PMID: 37793617 PMCID: PMC10550365 DOI: 10.1055/s-0043-1772686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 07/20/2023] [Indexed: 10/06/2023] Open
Abstract
OBJECTIVE Despite the benefits of the tailored drug-drug interaction (DDI) alerts and the broad dissemination strategy, the uptake of our tailored DDI alert algorithms that are enhanced with patient-specific and context-specific factors has been limited. The goal of the study was to examine barriers and health care system dynamics related to implementing tailored DDI alerts and identify the factors that would drive optimization and improvement of DDI alerts. METHODS We employed a qualitative research approach, conducting interviews with a participant interview guide framed based on Proctor's taxonomy of implementation outcomes and informed by the Theoretical Domains Framework. Participants included pharmacists with informatics roles within hospitals, chief medical informatics officers, and associate medical informatics directors/officers. Our data analysis was informed by the technique used in grounded theory analysis, and the reporting of open coding results was based on a modified version of the Safety-Related Electronic Health Record Research Reporting Framework. RESULTS Our analysis generated 15 barriers, and we mapped the interconnections of these barriers, which clustered around three entities (i.e., users, organizations, and technical stakeholders). Our findings revealed that misaligned interests regarding DDI alert performance and misaligned expectations regarding DDI alert optimizations among these entities within health care organizations could result in system inertia in implementing tailored DDI alerts. CONCLUSION Health care organizations primarily determine the implementation and optimization of DDI alerts, and it is essential to identify and demonstrate value metrics that health care organizations prioritize to enable tailored DDI alert implementation. This could be achieved via a multifaceted approach, such as partnering with health care organizations that have the capacity to adopt tailored DDI alerts and identifying specialists who know users' needs, liaise with organizations and vendors, and facilitate technical stakeholders' work. In the future, researchers can adopt the systematic approach to study tailored DDI implementation problems from other system perspectives (e.g., the vendors' system).
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Affiliation(s)
- Tianyi Zhang
- Department of Systems and Industrial Engineering, College of Engineering, University of Arizona, Tucson, Arizona
| | - Sheila M. Gephart
- Advanced Nursing Practice and Science Division, College of Nursing, University of Arizona, Tucson, Arizona
| | - Vignesh Subbian
- Department of Systems and Industrial Engineering, College of Engineering, University of Arizona, Tucson, Arizona
| | - Richard D. Boyce
- Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lorenzo Villa-Zapata
- Clinical and Administrative Pharmacy, College of Pharmacy, University of Georgia, Athens, Georgia
| | - Malinda S. Tan
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, Utah
| | - John Horn
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington
| | - Ainhoa Gomez-Lumbreras
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, Utah
| | | | - Daniel C. Malone
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, Utah
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Wildhagen FV, Neininger MP, Hensen J, Steinbeck A, Zube O, Bertsche T. An Observational Study to Identify Drug-related Problems (DRP) in Routine Care and An Expert Panel Assessment to Rate Clinical Risk and Preventability by Unit-dose Dispensing Systems (UDDS) with Computerized Physician Order Entry (CPOE) and Clinical Decision-Support Systems (CDSS). Pharmazie 2023; 78:134-140. [PMID: 37592416 DOI: 10.1691/ph.2023.3557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
Background and aim: Drug-related problems (DRP) jeopardize patient safety. Unit-dose dispensing systems (UDDS) with computerized-physician-order-entry (CPOE) and clinical-decision-support-systems (CDSS) were reported as a promising concept for preventing DRP. We aimed at identifying and categorizing DRP in peroral drug administration considering their clinical risk and preventability by UDSS/CPOE/CDSS. Investigations: In surgical and internal-medicine departments, we observed routine procedures in peroral drug administration for DRP. An expert panel including pharmaceutical and nursing expertise categorized the identified 18 DRP categories into three levels: DRP that have not yet resulted in medication errors (ME) (Level-I), DRP where ME have occurred but have not yet reached the patient (Level-II), and DRP where ME have occurred and have reached the patient (Level-III). Additionally, the panel categorized DRP according to their clinical risk and whether the implementation of UDSS/CPOE/CDSS can prevent them. Results: In 77 surgical patients, 1,849 peroral drug administration procedures, and in 149 internal-medicine patients, 1,405 procedures were observed. The 18 DRP categories were identified with a frequency of 0.6%-26.7% (Level-I), 0.1%-21.5% (Level-II), and 0.0%-1.0% (Level-III). Of those, four categories were considered of high clinical risk: "Name of the medication is not readable", "Prescribed medication is not prepared for administration", "An incorrect or non-prescribed medication is prepared", and "A medication is prepared for the wrong patient (mix-up)". Twelve DRP categories were categorized as highly preventable by UDSS/CPOE/CDSS. Conclusions:Under routine conditions, we identified a substantial number of DRPs. An expert panel categorized many of those DRPs as clinically highly relevant and highly preventable by UDSS/CPOE/CDSS.
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Affiliation(s)
| | | | | | | | | | - T Bertsche
- Clinical Pharmacy, Institute of Pharmacy, Medical Faculty, and Drug Safety Center, Leipzig University and Leipzig University Hospital, Brüderstraße 32, 04103 Leipzig, Germany
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Dahmke H, Fiumefreddo R, Schuetz P, De Iaco R, Zaugg C. Tackling alert fatigue with a semi-automated clinical decision support system: quantitative evaluation and end-user survey. Swiss Med Wkly 2023; 153:40082. [PMID: 37454289 DOI: 10.57187/smw.2023.40082] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023] Open
Abstract
STUDY AIMS Clinical decision support systems (CDSS) embedded in hospital electronic health records efficiently reduce medication errors, but there is a risk of low physician adherence due to alert fatigue. At the Cantonal Hospital Aarau, a CDSS is being developed that allows the highly accurate detection and correction of medication errors. The semi-automated CDSS sends its alerts either directly to the physician or to a clinical pharmacist for review first. Our aim was to evaluate the performance of the recently implemented CDSS in terms of acceptance rate and alert burden, as well as physicians' satisfaction with the CDSS. METHODS All alerts generated by the clinical decision support systems between January and December 2021 were included in a retrospective quantitative evaluation. A team of clinical pharmacists performed a follow-up to determine whether the recommendation made by the CDSS was implemented by the physician. The acceptance rate was calculated including all alerts for which it was possible to determine an outcome. A web-based survey was conducted amongst physicians to assess their attitude towards the CDSS. The survey questions included overall satisfaction, helpfulness of individual algorithms, and perceived alert burden. RESULTS In 2021, a total of 10,556 alerts were generated, of which 619 triggered a direct notification to the physician and 2,231 notifications were send to the physician after evaluation by a clinical pharmacist. The acceptance rates were 89.8% and 68.4%, respectively, which translates as an overall acceptance rate of 72.4%. On average, clinical pharmacists received 17.2 alerts per day, while all of the hospital physicians together received 7.8 notifications per day. In the survey, 94.5% of physicians reported being satisfied or very satisfied with the CDSS. Algorithms addressing potential medication errors concerning anticoagulants received the highest usefulness ratings. CONCLUSION The development of this semi-automated clinical decision support system with context-based algorithms resulted in alerts with a high acceptance rate. Involving clinical pharmacists proved a promising approach to limit the alert burden of physicians and thus tackle alert fatigue. The CDSS is well accepted by our physicians.
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Affiliation(s)
- Hendrike Dahmke
- Hospital Pharmacy, Kantonsspital Aarau, Aarau, Switzerland
- Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Rico Fiumefreddo
- Department of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Philipp Schuetz
- Department of General Internal and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | | | - Claudia Zaugg
- Hospital Pharmacy, Kantonsspital Aarau, Aarau, Switzerland
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Jumeau M, Francois O, Bonnabry P. Impact of automated dispensing cabinets on dispensing errors, interruptions and pillbox preparation time. Eur J Hosp Pharm 2023; 30:237-241. [PMID: 34426488 PMCID: PMC10359777 DOI: 10.1136/ejhpharm-2021-002849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/10/2021] [Indexed: 11/04/2022] Open
Abstract
AIM This work aimed to evaluate the impact of automated dispensing cabinets on the dispensing error rate, the number of interruptions, and pillbox preparation times. METHODS A prospective observational study was conducted across 16 wards in two departments (internal medicine and surgery) of a large teaching hospital. The study compared eight wards using automated dispensing cabinets (ADCs) and eight using a traditional ward stock (TWS) method. A disguised observation technique was used to compare occurrences of dispensing errors and interruptions and pillbox preparation times. The proportion of errors was calculated by dividing the number of doses with one or more errors by the total number of opportunities for error. Wards participating in the 'More time for patients' project-a Lean Management approach-were compared with those not participating. The potential severity of intercepted errors was assessed. RESULTS Our observations recorded 2924 opportunities for error in the preparation of 570 pillboxes by 132 nurses. We measured a significantly lower overall error rate (1.0% vs 5.0%, p=0.0001), significantly fewer interruptions per hour (3.2 vs 5.7, p=0.008), and a significantly faster mean preparation time per drug (32 s vs 40 s, p=0.0017) among ADC wards than among TWS wards, respectively. We observed a significantly lower overall error rate (1.4% vs 4.4%, p=0.0268) and a non-significantly lower number of interruptions per hour (3.8 vs 5.1, p=0.0802) among wards participating in the 'More time for patients' project. CONCLUSIONS A high dispensing-error rate was observed among wards using TWS methods. Wards using ADCs connected to computerised physician order entry and installed in a dedicated room had fewer dispensing errors and interruptions and their nurses prepared pillboxes faster. Wards participating in a Lean Management project had lower error rates than wards not using this approach.
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Affiliation(s)
- Margaux Jumeau
- Pharmacy, Geneva University Hospitals, Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, School ofPharmaceutical Sciences, University of Geneva, Geneva, Switzerland
| | | | - Pascal Bonnabry
- Pharmacy, Geneva University Hospitals, Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, School ofPharmaceutical Sciences, University of Geneva, Geneva, Switzerland
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E. Dawson T, Beus J, W. Orenstein E, Umontuen U, McNeill D, Kandaswamy S. Reducing Therapeutic Duplication in Inpatient Medication Orders. Appl Clin Inform 2023; 14:538-543. [PMID: 37105228 PMCID: PMC10356184 DOI: 10.1055/a-2082-4631] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/25/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Therapeutic duplication, the presence of multiple agents prescribed for the same indication without clarification for when each should be used, can contribute to serious medical errors. Joint Commission standards require that orders contain clarifying information about when each order should be given. In our system, as needed (PRN) acetaminophen and ibuprofen orders are major contributors to therapeutic duplication. OBJECTIVE The objective of this study is to design and evaluate effectiveness of clinical decision support (CDS) to reduce therapeutic duplication with acetaminophen and ibuprofen orders. METHODS This study was done in a pediatric health system with three freestanding hospitals. We iteratively designed and implemented two CDS strategies aimed at reducing the therapeutic duplication with these agents: (1) interruptive alert prompting clinicians for clarifying PRN comments at order entry and (2) addition of discrete "first-line" and "second-line" PRN reasons to orders. Therapeutic duplications were measured by manual review of orders for 30-day periods before and after each intervention and 6 months later. RESULTS Therapeutic duplications decreased from 1,485 in the 30 days prior to the first alert implementation to 818 in the 30 days after but rose back to 1,208 in the 30 days prior to the second intervention. After discrete reasons were added to the order, therapeutic duplication decreased to 336 in the immediate 30 days and 6 months later remained at 277. Alerts firing rates decreased from 76.0 per 1,000 PRN acetaminophen or ibuprofen orders to 42.9 after the second intervention. CONCLUSION Interruptive alerts may reduce therapeutic duplication but are associated with high rates of user frustration and alert fatigue. Leveraging discrete PRN reasons for "first line" and "second line" produced a greater reduction in therapeutic duplication as well as fewer interruptive alerts and less manual entry for providers.
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Affiliation(s)
- Thomas E. Dawson
- Department of Information Systems & Technology, Children's Healthcare of Atlanta, Atlanta, Georgia, United States
| | - Jonathan Beus
- Department of Information Systems & Technology, Children's Healthcare of Atlanta, Atlanta, Georgia, United States
- Department of pediatrics, Emory University, Atlanta, Georgia, United States
| | - Evan W. Orenstein
- Department of Information Systems & Technology, Children's Healthcare of Atlanta, Atlanta, Georgia, United States
- Department of pediatrics, Emory University, Atlanta, Georgia, United States
| | - Uwem Umontuen
- Department of Information Systems & Technology, Children's Healthcare of Atlanta, Atlanta, Georgia, United States
| | - Denice McNeill
- Department of Clinical Development & Medical Affairs, PharmaEssentia USA Corporation, Burlington, Massachusetts, United States
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Osmani F, Arab-Zozani M, Shahali Z, Lotfi F. Evaluation of the effectiveness of electronic prescription in reducing medical and medical errors (systematic review study). Ann Pharm Fr 2023; 81:433-445. [PMID: 36513154 PMCID: PMC9737496 DOI: 10.1016/j.pharma.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 08/29/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The use of electronic systems in prescription is considered as the final solution to overcome the many problems of the paper transcription process, especially with the outbreak of Coronavirus needs more attention than before. But despite the many advantages, its implementation faces many challenges and obstacles. Therefore, the present study was conducted to review the effectiveness of computerized physician order entry systems (CPOE) on relative risk reduction on medication error and adverse drug events (ADE). METHOD This study is one of the systematic review studies that was conducted in 2021. In this study, searching for keywords such as E-Electronic Prescription, Patient safety, Medication Errors prescription, Drug Interactions, orginal articles from 2000 to October-2020 in the valid databases such as ISI web of Science PubMed Embase, Scopus and search engines like google was done. The included studies were based on the main objectives of the study and based on the inclusion criteria after several stages of review and quality evaluation. In fact, the main criteria for selecting articles were studies that compared the rate of medication errors with or without assessing the associated harms (real or potential) before and after the implementation of EMS. RESULTS Out of 110 selected studies after initial screening, only 16 articles were selected due to their relevance. Among the final studies, there was a significant heterogeneity. Only 6 studies were of good quality. Of the 10 studies prescribing error rates, 9 reported reductions, but variable denominators prevented meta-analysis. Twelve studies provided specific examples of systemic drug errors. 5 cases reported their occurrence slightly. Out of 9 cases that analyzed the effects on drug error rate, 7 cases showed a significant relative reduction between 13 and 99%. Four of the six studies that analyzed the effects on potential ADEs showed a significant relative reduction of between 35 and 98%. Two of the four studies that analyzed the effect of ADEs showed a relative reduction of between 30 and 84%. CONCLUSION Finally, e-prescribing seems to reduce the risk of medication errors and ADE. However, the studies differed significantly in terms of setting, design, quality and results. More randomized controlled trials (RCTs) are needed to further improve the evidence of health informatics information.
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Affiliation(s)
- F Osmani
- Infection disease Research center, Birjand University of Medical Sciences, Birjand, Iran.
| | - M Arab-Zozani
- Social Determinants of Health Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | - Z Shahali
- National Center for Health Insurance Research, Tehran, Iran
| | - F Lotfi
- National Center for Health Insurance Research, Tehran, Iran
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Grauer A, Rosen A, Applebaum JR, Carter D, Reddy P, Dal Col A, Kumaraiah D, Barchi DJ, Classen DC, Adelman JS. Examining medication ordering errors using AHRQ network of patient safety databases. J Am Med Inform Assoc 2023; 30:838-845. [PMID: 36718575 PMCID: PMC10114013 DOI: 10.1093/jamia/ocad007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 01/11/2023] [Accepted: 01/19/2023] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Studies examining the effects of computerized order entry (CPOE) on medication ordering errors demonstrate that CPOE does not consistently prevent these errors as intended. We used the Agency for Healthcare Research and Quality (AHRQ) Network of Patient Safety Databases (NPSD) to investigate the frequency and degree of harm of reported events that occurred at the ordering stage, characterized by error type. MATERIALS AND METHODS This was a retrospective observational study of safety events reported by healthcare systems in participating patient safety organizations from 6/2010 through 12/2020. All medication and other substance ordering errors reported to NPSD via common format v1.2 between 6/2010 through 12/2020 were analyzed. We aggregated and categorized the frequency of reported medication ordering errors by error type, degree of harm, and demographic characteristics. RESULTS A total of 12 830 errors were reported during the study period. Incorrect dose accounted for 3812 errors (29.7%), followed by incorrect medication 2086 (16.3%), and incorrect duration 765 (6.0%). Of 5282 events that reached the patient and had a known level of severity, 12 resulted in death, 4 resulted in severe harm, 45 resulted in moderate harm, 341 resulted in mild harm, and 4880 resulted in no harm. CONCLUSION Incorrect dose and incorrect drug orders were the most commonly reported and harmful types of medication ordering errors. Future studies should aim to develop and test interventions focused on CPOE to prevent medication ordering errors, prioritizing wrong-dose and wrong-drug errors.
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Affiliation(s)
- Anne Grauer
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
- Department of Quality and Patient Safety, New York-Presbyterian Hospital, New York, New York, USA
| | - Amanda Rosen
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
- Department of Quality and Patient Safety, New York-Presbyterian Hospital, New York, New York, USA
| | - Jo R Applebaum
- Department of Quality and Patient Safety, New York-Presbyterian Hospital, New York, New York, USA
| | - Danielle Carter
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
- Department of Quality and Patient Safety, New York-Presbyterian Hospital, New York, New York, USA
| | - Pooja Reddy
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York, USA
| | - Alexis Dal Col
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Deepa Kumaraiah
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
- Department of Quality and Patient Safety, New York-Presbyterian Hospital, New York, New York, USA
| | - Daniel J Barchi
- Department of Quality and Patient Safety, New York-Presbyterian Hospital, New York, New York, USA
| | - David C Classen
- Division of Clinical Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jason S Adelman
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
- Department of Quality and Patient Safety, New York-Presbyterian Hospital, New York, New York, USA
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Vittery ER, Bayliss E, Heed A, Fagan C, Thomas M, Tse Y. Reducing prescribing errors: making electronic prescribing work for cystic fibrosis inpatients. Arch Dis Child Educ Pract Ed 2023; 108:112-114. [PMID: 35264442 DOI: 10.1136/archdischild-2021-322446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 02/11/2022] [Indexed: 11/04/2022]
Abstract
Children admitted to our hospital with cystic fibrosis had frequent medication errors due to polypharmacy and addition of specialist and high-risk medications despite an electronic prescribing and medicines administration system in place. We describe a multidisciplinary quality improvement project that combined a computerised order entry system (CPOE) with human factor process changes. Over 12 months, our run chart showed a 43% reduction in prescription errors. For medications prescribable via the CPOE, errors reaching the patient reduced from 50% to 29%. Electronic prescribing can be seen by clinicians as a fixed unalterable system contributing to rather than ameliorating errors. Improving safety requires whole team engagement and working closely with programmers to adapt function and influence human factors.
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Affiliation(s)
| | - Emily Bayliss
- Department of Paediatric Pharmacy, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
| | - Andrew Heed
- Department of Clinical Informatics Pharmacy, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
| | - Claire Fagan
- Department of Respiratory Paediatrics, Great North Children's Hospital, Newcastle Upon Tyne, UK
| | - Matthew Thomas
- Department of Respiratory Paediatrics, Great North Children's Hospital, Newcastle Upon Tyne, UK
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Yincent Tse
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Great North Children's Hospital, Newcastle Upon Tyne, UK
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Liu KW, Shih YF, Chiang YJ, Chen LJ, Lee CH, Chen HN, Chen JY, Hsiao CC. Reducing Medication Errors in Children's Hospitals. J Patient Saf 2023; 19:151-157. [PMID: 36728168 DOI: 10.1097/pts.0000000000001087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Knowledge of the prevalence and characteristics of medication errors in pediatric and neonatal patients is limited. This study aimed to evaluate the incidence and medication error characteristics in a pediatric hospital over 5 years and to determine whether serial error prevention programs to optimize a computerized physician order entry (CPOE) system reduce error incidence. METHODS We retrospectively reviewed medication errors documented between January 2015 and December 2019. RESULTS A total of 2,591,596 prescriptions were checked, and 255 errors were identified. Wrong dose prescriptions constituted the most common errors (56.9%). Medications with the highest rate of errors were antibiotics/antiviral drugs (36.9%). Oral route medications comprised the highest portion (60.8%), followed by intravenous ones (28.6%). The most common stage for medication errors was physician ordering (93.3%). Junior residents were responsible for most errors (45.9%). Most errors occurred in the pediatric ward (53.7%). In total, 221 (86.7%) errors were near misses. Only 4 errors (1.6%) were considered significant and required active monitoring or intervention. Type of error, stage of error, staff composition, and severity level of errors were significantly related to the number of errors in different years. There was a statistically significant decrease in errors per 100,000 prescriptions across different years after optimizing the CPOE system. CONCLUSIONS The incidence of medication errors decreased with extensive use of the CPOE system. Continuous application of the CPOE optimization program can effectively reduce medication errors. Further incorporation of pediatric-specific decision-making and support tools and error prevention measures into CPOE systems is needed.
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Affiliation(s)
- Kai-Wen Liu
- From the Department of Neonatology, Changhua Christian Children's Hospital
| | - Ya-Fen Shih
- Department of Pharmacy, Changhua Christian Hospital, Changhua
| | - Yi-Jung Chiang
- Department of Pharmacy, Changhua Christian Hospital, Changhua
| | - Lih-Ju Chen
- From the Department of Neonatology, Changhua Christian Children's Hospital
| | - Cheng-Han Lee
- From the Department of Neonatology, Changhua Christian Children's Hospital
| | - Hsiao-Neng Chen
- From the Department of Neonatology, Changhua Christian Children's Hospital
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Barra ME, Webb AJ, Roberts RJ, Ross M, Hallisey R, Szumita P, Guidon AC. Implementation of a myasthenia gravis drug-disease interaction clinical decision support tool reduces prescribing of high-risk medications. Muscle Nerve 2023; 67:284-290. [PMID: 36691226 DOI: 10.1002/mus.27790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 01/08/2023] [Accepted: 01/11/2023] [Indexed: 01/25/2023]
Abstract
INTRODUCTION/AIMS High-risk medication exposure is a modifiable risk factor for myasthenic exacerbation and crisis. We evaluated whether real-time electronic clinical decision support (CDS) was effective in reducing the rate of prescribing potentially high-risk medications to avoid or use with caution in patients with myasthenia gravis. METHODS An expert panel reviewed the available drug-disease pairings and associated severity levels to activate the alerts for CDS. All unique alerts activated in both inpatient and outpatient contexts were analyzed over a two-year period. Clinical context, alert severity, medication class, and alert action were collected. The primary outcome was alert override rate. Secondary outcomes included the percentage of unique medication exposures avoided and predictors of alert override. RESULTS During the analysis period, 2817 unique alerts fired, representing 830 distinct patient-medication exposures for 577 unique patients. The overall alert override rate was 85% (80.3% for inpatient alerts and 95.8% for outpatient alerts). Of unique medication-patient exposures, 19% were avoided because of the alert. Assigned alert severity of "contraindicated" were less likely to be overridden (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.32-0.56), as well as alerts activated during evening staffing (OR 0.69, 95% CI 0.55-0.87). DISCUSSION Implementation of a myasthenia gravis drug-disease interaction alert reduced overall patient exposure to potentially harmful medications by approximately 19%. Future optimization includes enhanced provider and pharmacist education. Further refinement of alert logic criteria to optimize medication risk reduction and reduce alert fatigue is warranted to support clinicians in prescribing and reduce electronic health record time burden.
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Affiliation(s)
- Megan E Barra
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Andrew J Webb
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Russel J Roberts
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marjorie Ross
- Department of Neurology, Newton Wellesley Hospital, Newton Lower Falls, Massachusetts, USA
| | - Robert Hallisey
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Paul Szumita
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Amanda C Guidon
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Desmaris RP, Roche M, Mitha A, Azam S, Blazy V, Rieutord A, Aboudagga H. Automated preparation of cytotoxic drugs: the evidence for an interface between the robot and computerized provider order entry? Eur J Hosp Pharm 2023; 30:e12. [PMID: 35273004 PMCID: PMC9986918 DOI: 10.1136/ejhpharm-2022-003234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
| | - Mathilde Roche
- Department of Clinical Pharmacy, Gustave Roussy, Villejuif, Île-de-France, France
| | - Assia Mitha
- Department of Clinical Pharmacy, Gustave Roussy, Villejuif, Île-de-France, France
| | - Sabine Azam
- Department of Information Technology and Digital Transformation, Gustave Roussy, Villejuif, Île-de-France, France
| | - Vincent Blazy
- Department of Information Technology and Digital Transformation, Gustave Roussy, Villejuif, Île-de-France, France
| | - Andre Rieutord
- Department of Clinical Pharmacy, Gustave Roussy, Villejuif, Île-de-France, France
| | - Hail Aboudagga
- Department of Clinical Pharmacy, Gustave Roussy, Villejuif, Île-de-France, France
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Kadura S, Siala T, Arora VM. Perspective: leveraging the electronic health record to improve sleep in the hospital. J Clin Sleep Med 2023; 19:421-423. [PMID: 36448329 PMCID: PMC9892746 DOI: 10.5664/jcsm.10360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 09/05/2022] [Accepted: 10/16/2022] [Indexed: 12/05/2022]
Abstract
Inpatient sleep loss can worsen health outcomes, including delirium and falls. Sleep disruptions in the hospital often originate from provider-patient interactions ordered electronically through computerized provider order entry. These orders contain clinical decision support systems with default schedules. These defaults are often around-the-clock, may not align with patients' needs, and cause iatrogenic sleep loss. Optimizing clinical decision support in the electronic health record can decrease unnecessary sleep disruptions and influence sleep-friendly decision-making. CITATION Kadura S, Siala T, Arora VM. Perspective: Leveraging the electronic health record to improve sleep in the hospital. J Clin Sleep Med. 2023;19(2):421-423.
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Affiliation(s)
- Sullafa Kadura
- University of Rochester Medical Center, Rochester, New York
| | - Tarek Siala
- University of Rochester Medical Center, Rochester, New York
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Murad DA, Tsugawa Y, Elashoff DA, Baldwin KM, Bell DS. Distinct components of alert fatigue in physicians' responses to a noninterruptive clinical decision support alert. J Am Med Inform Assoc 2022; 30:64-72. [PMID: 36264258 PMCID: PMC9748542 DOI: 10.1093/jamia/ocac191] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 10/10/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE Clinical decision support (CDS) alerts may improve health care quality but "alert fatigue" can reduce provider responsiveness. We analyzed how the introduction of competing alerts affected provider adherence to a single depression screening alert. MATERIALS AND METHODS We analyzed the audit data from all occurrences of a CDS alert at a large academic health system. For patients who screen positive for depression during ambulatory visits, a noninterruptive alert was presented, offering a number of relevant documentation actions. Alert adherence was defined as the selection of any option offered within the alert. We assessed the effect of competing clinical guidance alerts presented during the same encounter and the total of all CDS alerts that the same provider had seen in the prior 90 days, on the probability of depression screen alert adherence, adjusting for physician and patient characteristics. RESULTS The depression alert fired during 55 649 office visits involving 418 physicians and 40 474 patients over 41 months. After adjustment, physicians who had seen the most alerts in the prior 90 days were much less likely to respond (adjusted OR highest-lowest quartile, 0.38; 95% CI 0.35-0.42; P < .001). Competing alerts in the same visit further reduced the likelihood of adherence only among physicians in the middle two quartiles of alert exposure in the prior 90 days. CONCLUSIONS Adherence to a noninterruptive depression alert was strongly associated with the provider's cumulative alert exposure over the past quarter. Health systems should monitor providers' recent alert exposure as a measure of alert fatigue.
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Affiliation(s)
- Douglas A Murad
- Medical Informatics, Kaiser Permanente Southern California, San Diego, CA, USA
| | - Yusuke Tsugawa
- Division of General Internal Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - David A Elashoff
- Division of General Internal Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | - Douglas S Bell
- Division of General Internal Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- UCLA Health Information Technology, Los Angeles, CA, USA
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Ho VT, Aikens RC, Tso G, Heidenreich PA, Sharp C, Asch SM, Chen JH, Shah NK. Interruptive Electronic Alerts for Choosing Wisely Recommendations: A Cluster Randomized Controlled Trial. J Am Med Inform Assoc 2022; 29:1941-1948. [PMID: 36018731 PMCID: PMC10161518 DOI: 10.1093/jamia/ocac139] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 07/13/2022] [Accepted: 08/17/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To assess the efficacy of interruptive electronic alerts in improving adherence to the American Board of Internal Medicine's Choosing Wisely recommendations to reduce unnecessary laboratory testing. MATERIALS AND METHODS We administered 5 cluster randomized controlled trials simultaneously, using electronic medical record alerts regarding prostate-specific antigen (PSA) testing, acute sinusitis treatment, vitamin D testing, carotid artery ultrasound screening, and human papillomavirus testing. For each alert, we assigned 5 outpatient clinics to an interruptive alert and 5 were observed as a control. Primary and secondary outcomes were the number of postalert orders per 100 patients at each clinic and number of triggered alerts divided by orders, respectively. Post hoc analysis evaluated whether physicians experiencing interruptive alerts reduced their alert-triggering behaviors. RESULTS Median postalert orders per 100 patients did not differ significantly between treatment and control groups; absolute median differences ranging from 0.04 to 0.40 for PSA testing. Median alerts per 100 orders did not differ significantly between treatment and control groups; absolute median differences ranged from 0.004 to 0.03. In post hoc analysis, providers receiving alerts regarding PSA testing in men were significantly less likely to trigger additional PSA alerts than those in the control sites (Incidence Rate Ratio 0.12, 95% CI [0.03-0.52]). DISCUSSION Interruptive point-of-care alerts did not yield detectable changes in the overall rate of undesired orders or the order-to-alert ratio between active and silent sites. Complementary behavioral or educational interventions are likely needed to improve efforts to curb medical overuse. CONCLUSION Implementation of interruptive alerts at the time of ordering was not associated with improved adherence to 5 Choosing Wisely guidelines. TRIAL REGISTRATION NCT02709772.
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Affiliation(s)
- Vy T Ho
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Rachael C Aikens
- Department of Biomedical Informatics, Stanford University School of Medicine, Stanford, California, USA
| | - Geoffrey Tso
- Division of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, California, USA
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California, USA
| | - Christopher Sharp
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Steven M Asch
- Division of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, California, USA
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California, USA
| | - Jonathan H Chen
- Stanford Center for Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, California, USA
| | - Neil K Shah
- Department of Pathology, Stanford University School of Medicine, Stanford, California, USA
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Luri M, Gastaminza G, Idoate A, Ortega A. Allergic Adverse Drug Events After Alert Overrides in Hospitalized Patients. J Patient Saf 2022; 18:630-636. [PMID: 35617638 DOI: 10.1097/pts.0000000000001034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This study aimed to assess how often overridden drug allergy alerts (ODAAs) lead to allergic adverse drug events (All-ADEs) and to evaluate the frequency with which drug allergy alerts (DAAs) were overridden and the reasons, as well as appropriateness of these overrides. METHODS A retrospective observational study of DAA generated between 2014 and 2016 was conducted. The corresponding DAA records were reviewed to determine the frequency of alert overrides. A chart review was performed on a subset of 194 ODAA (the first of every 3 chronologically ordered ODAA) to identify All-ADEs and to evaluate the override reasons and the appropriateness of these overrides. RESULTS A total of 2044 DAAs were overridden (override rate of 44.8%). Most were triggered by a nonexact match (93.81%), when ordering nervous system (21.1%) and cardiovascular system (19.6%) drugs and were generated by physicians (72.7%). The main override reason was that the patient was already taking the drug or had previously tolerated the drug. Only 9.28% of ODAAs were inappropriately overridden. Six All-ADEs (3.09%) were identified and were due to anti-infective (1), antineoplastic (1), and iodinated-contrast (4) drug administration. Most All-ADEs were cutaneous and were mild. None was life-threatening or fatal. The All-ADEs rate was higher among inappropriately ODAA (15.79%, P = 0.013). CONCLUSIONS Alert overrides are not exempt from clinical consequences, although few are associated with All-ADEs. It is necessary to identify the drugs involved in those reactions and to update allergy lists to generate only specific and important DAA and to avoid the negative consequences of overrides.
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Kandaswamy S, Grimes J, Hoffman D, Marquard J, Ratwani RM, Hettinger AZ. Free-Text Computerized Provider Order Entry Orders Used as Workaround for Communicating Medication Information. J Patient Saf 2022; 18:430-434. [PMID: 35948292 PMCID: PMC9366105 DOI: 10.1097/pts.0000000000000948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Medication information is frequently communicated via free-text computerized provider order entry (CPOE) orders in electronic health records. When such information is transmitted separately from a structured CPOE medication order, there is a significant risk of medication error. Although prior studies have described the frequency of using free-text CPOE orders for communicating medication information, there is a gap in understanding the nature of the medication information contained in the free-text CPOE orders. The aims of this study are to (1) identify the most common medication names communicated in free-text CPOE orders and their risk levels and (2) identify what actions physicians expect that nurses will complete when they place free-text CPOE orders, and (3) describe differences in these patterns across hospitals. METHODS This study was a retrospective analysis of a sample of 26,524 free-text CPOE orders from 6 hospitals in the mid-Atlantic U.S. region. RESULTS Free-text CPOE orders contained in the sample mentioned 193 medication names. Free-text CPOE orders were used frequently to communicate information about naloxone, heparin, flumazenil, and dextrose. Twenty-two percent of the free-text CPOE orders related to discontinuing medication(s), whereas 7% of the free-text CPOE orders relate to giving medication(s). There was high variation across hospitals both in the percentage of free-text CPOE orders mentioning medication information and in the proportion of those that referred to high-risk medications. CONCLUSIONS The prevalence of medication information in free-text CPOE orders may suggest specific communication challenges in respect to urgency, uncertainty, planning, and other aspects of communication and clinical needs. Understanding and addressing communication challenges around commonly mentioned medication names and actions, especially those that are high risk, can help reduce the risk of medication errors.
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Affiliation(s)
| | - Joanna Grimes
- MedStar Health National Center for Human Factors in
Healthcare
- Georgetown University School of Medicine
| | - Daniel Hoffman
- Robert H. Smith School of Business, University of
Maryland
| | | | - Raj M Ratwani
- MedStar Health National Center for Human Factors in
Healthcare
- Georgetown University School of Medicine
| | - Aaron Z Hettinger
- MedStar Health National Center for Human Factors in
Healthcare
- Georgetown University School of Medicine
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Villa Zapata L, Subbian V, Boyce RD, Hansten PD, Horn JR, Gephart SM, Romero A, Malone DC. Overriding Drug-Drug Interaction Alerts in Clinical Decision Support Systems: A Scoping Review. Stud Health Technol Inform 2022; 290:380-384. [PMID: 35673040 DOI: 10.3233/shti220101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Ineffective computerized alerts for potential Drug-Drug Interactions (DDI) is a longstanding informatics issue. Prescribing clinicians often ignore or override such alerts due to lack of context and clinical relevance, among various other reasons. In this study, we reveiwed published data on the rate of DDI alert overrides and medications involved in the overrides. We identified 34 eligible studies from sites across Asia, Europe, the United States, and the United Kingdom. The override rate of DDI alerts ranged from 55% to 98%, with more than half of the studies reporting the most common drug pairs or medications involved in acceptance or overriding of alerts. The high prevalance of alert overrides highlights the need for decision support systems that take user, drug, and institutional factors into consideration, as well as actionable metrics to better characterize harm associated with overrides.
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Affiliation(s)
- Lorenzo Villa Zapata
- Department of Pharmacy Practice, College of Pharmacy, Mercer University, Atlanta, Georgia, USA
| | - Vignesh Subbian
- College of Engineering, The University of Arizona, Tucson, Arizona, USA
| | - Richard D Boyce
- Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Philip D Hansten
- School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - John R Horn
- School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Sheila M Gephart
- College of Nursing, The University of Arizona, Tucson, Arizona, USA
| | - Andrew Romero
- Department of Pharmacy, Banner University Medical Center, Tucson, Arizona, USA
| | - Daniel C Malone
- College of Pharmacy, L.S. Skaggs Research Institute, University of Utah, Salt Lake City, Utah, USA
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Frutos EL, Muñoz AM, Rovegno L, Pedretti AS, Otero CM, Gimenez C, Luna DR, Grande Ratti MF, Martinez BJ. Can CPOE Based on Electronic Order Sets Cause Unintended Consequences (Expensive and Unnecessary Tests) at the Emergency Department? Stud Health Technol Inform 2022; 290:192-196. [PMID: 35672998 DOI: 10.3233/shti220059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Computerized Provider Order Entry (CPOE) systems may cause unintended consequences. This study aimed to describe the on-going system for CPOE order sets, and to explore an economic evaluation at the Emergency Department. First, we developed a costs dashboard which showed us the significant and excessive use of medical tests per consultation. We identified the top 10 most widely used and most expensive tests. Additionally we noticed that the labs seemed to continually increase. Then, we found that 27% of the consultations have at least one item of laboratory practice between January and February 2020, and this represents more than 80% of the consultation costs. Health care spending has reached epic proportions globally. We think that it is time to rethink effective strategies. Maybe it is time to deactivate/remove electronic order sets (EOSs) and the functionality to develop and create their own "private" order sets, in order to eliminate waste and inefficiencies.
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Affiliation(s)
- Eliana Ludmila Frutos
- Department of Health Informatics, Hospital Italiano de Buenos Aires, Ciudad de Buenos Aires, Argentina
| | - Agustín Matías Muñoz
- Emergency Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Luciana Rovegno
- Emergency Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Ana Soledad Pedretti
- Emergency Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Carlos Martin Otero
- Department of Health Informatics, Hospital Italiano de Buenos Aires, Ciudad de Buenos Aires, Argentina
| | - Cintia Gimenez
- Department of Health Informatics, Hospital Italiano de Buenos Aires, Ciudad de Buenos Aires, Argentina
| | - Daniel Roberto Luna
- Department of Health Informatics, Hospital Italiano de Buenos Aires, Ciudad de Buenos Aires, Argentina
| | - María Florencia Grande Ratti
- Department of Health Informatics, Hospital Italiano de Buenos Aires, Ciudad de Buenos Aires, Argentina
- Emergency Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Devarajan V, Nadeau NL, Creedon JK, Dribin TE, Lin M, Hirsch AW, Neal JT, Stewart A, Popovsky E, Levitt D, Hoffmann JA, Lee M, Perron C, Shah D, Eisenberg MA, Hudgins JD. Reducing Pediatric Emergency Department Prescription Errors. Pediatrics 2022; 149:e2020014696. [PMID: 35641470 PMCID: PMC10680440 DOI: 10.1542/peds.2020-014696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/03/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Prescription errors are a significant cause of iatrogenic harm in the health care system. Pediatric emergency department (ED) patients are particularly vulnerable to error. We sought to decrease prescription errors in an academic pediatric ED by 20% over a 24-month period by implementing identified national best practice guidelines. METHODS From 2017 to 2019, a multidisciplinary, fellow-driven quality improvement (QI) project was conducted using the Model for Improvement. Four key drivers were identified including simplifying the electronic order entry into prescription folders, improving knowledge of dosing by indication, increasing error feedback to prescribers, and creating awareness of common prescription pitfalls. Four interventions were subsequently implemented. Outcome measures included prescription errors per 1000 prescriptions written for all medications and top 10 error-prone antibiotics. Process measures included provider awareness and use of prescription folders; the balancing measure was provider satisfaction. Differences in outcome measures were assessed by statistical process control methodology. Process and balancing measures were analyzed using 1-way analysis of variance and χ2 testing. RESULTS Before our interventions, 8.6 errors per 1000 prescriptions written were identified, with 62% of errors from the top 10 most error-prone antibiotics. After interventions, error rate per 1000 prescriptions decreased from 8.6 to 4.5 overall and from 20.1 to 8.8 for top 10 error-prone antibiotics. Provider awareness of prescription folders was significantly increased. CONCLUSION QI efforts to implement previously defined best practices, including simplifying and standardizing computerized provider order entry (CPOE), significantly reduced prescription errors. Synergistic effect of educational and technological efforts likely contributed to the measured improvement.
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Affiliation(s)
- Veena Devarajan
- Division of Emergency Medicine, Seattle Children’s Hospital, Seattle, Washington
| | - Nicole L. Nadeau
- Division of Pediatric Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Jessica K. Creedon
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Boston Children’s Hospital, Boston, Massachusetts
| | - Timothy E. Dribin
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Margaret Lin
- Department of Emergency Medicine and Pediatrics, University of California, San Francisco, California
| | - Alexander W. Hirsch
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Boston Children’s Hospital, Boston, Massachusetts
| | - Jeffrey T. Neal
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Boston Children’s Hospital, Boston, Massachusetts
| | - Amanda Stewart
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Boston Children’s Hospital, Boston, Massachusetts
| | - Erica Popovsky
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Danielle Levitt
- Division of Emergency and Transport, Children’s Hospital Los Angeles, Los Angeles, California
| | - Jennifer A. Hoffmann
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michael Lee
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Boston Children’s Hospital, Boston, Massachusetts
| | - Catherine Perron
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Boston Children’s Hospital, Boston, Massachusetts
| | - Dhara Shah
- Department of Pharmacy, Boston Children’s Hospital, Boston, Massachusetts
| | - Matthew A. Eisenberg
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Boston Children’s Hospital, Boston, Massachusetts
| | - Joel D. Hudgins
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts
- Boston Children’s Hospital, Boston, Massachusetts
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McCoy AB, Russo EM, Johnson KB, Addison B, Patel N, Wanderer JP, Mize DE, Jackson JG, Reese TJ, Littlejohn S, Patterson L, French T, Preston D, Rosenbury A, Valdez C, Nelson SD, Aher CV, Alrifai MW, Andrews J, Cobb C, Horst SN, Johnson DP, Knake LA, Lewis AA, Parks L, Parr SK, Patel P, Patterson BL, Smith CM, Suszter KD, Turer RW, Wilcox LJ, Wright AP, Wright A. Clinician collaboration to improve clinical decision support: the Clickbusters initiative. J Am Med Inform Assoc 2022; 29:1050-1059. [PMID: 35244165 PMCID: PMC9093034 DOI: 10.1093/jamia/ocac027] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 01/19/2022] [Accepted: 02/16/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE We describe the Clickbusters initiative implemented at Vanderbilt University Medical Center (VUMC), which was designed to improve safety and quality and reduce burnout through the optimization of clinical decision support (CDS) alerts. MATERIALS AND METHODS We developed a 10-step Clickbusting process and implemented a program that included a curriculum, CDS alert inventory, oversight process, and gamification. We carried out two 3-month rounds of the Clickbusters program at VUMC. We completed descriptive analyses of the changes made to alerts during the process, and of alert firing rates before and after the program. RESULTS Prior to Clickbusters, VUMC had 419 CDS alerts in production, with 488 425 firings (42 982 interruptive) each week. After 2 rounds, the Clickbusters program resulted in detailed, comprehensive reviews of 84 CDS alerts and reduced the number of weekly alert firings by more than 70 000 (15.43%). In addition to the direct improvements in CDS, the initiative also increased user engagement and involvement in CDS. CONCLUSIONS At VUMC, the Clickbusters program was successful in optimizing CDS alerts by reducing alert firings and resulting clicks. The program also involved more users in the process of evaluating and improving CDS and helped build a culture of continuous evaluation and improvement of clinical content in the electronic health record.
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Affiliation(s)
- Allison B McCoy
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- HeathIT, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Elise M Russo
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kevin B Johnson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- HeathIT, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bobby Addison
- HeathIT, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Neal Patel
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- HeathIT, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan P Wanderer
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- HeathIT, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dara E Mize
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- HeathIT, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Medicine, Division of Diabetes, Endocrinology and Metabolism, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jon G Jackson
- HeathIT, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Thomas J Reese
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - SyLinda Littlejohn
- HeathIT, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lorraine Patterson
- HeathIT, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Tina French
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Debbie Preston
- HeathIT, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Audra Rosenbury
- HeathIT, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Charlie Valdez
- HeathIT, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Scott D Nelson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- HeathIT, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Chetan V Aher
- HeathIT, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mhd Wael Alrifai
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- HeathIT, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jennifer Andrews
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cheryl Cobb
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sara N Horst
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David P Johnson
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lindsey A Knake
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Adam A Lewis
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Laura Parks
- Nursing Informatics Services, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sharidan K Parr
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- HeathIT, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Pratik Patel
- Union University College of Pharmacy, Memphis, Tennessee, USA
| | - Barron L Patterson
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christine M Smith
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Krystle D Suszter
- Nursing Informatics Services, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert W Turer
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lyndy J Wilcox
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Aileen P Wright
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Adam Wright
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- HeathIT, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Abbassi A, Hasni N, Ben Hamida EB. Impact of computerized physician order entry system on parenteral nutrition medication errors in a teaching neonatal intensive care unit. Ann Pharm Fr 2022; 80:819-826. [PMID: 35568248 DOI: 10.1016/j.pharma.2022.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 05/10/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Parenteral nutrition (PN) offers a quality therapeutic option when enteral feeding is non-tolerated or impossible. However, it can be associated with an increased risk of medical errors, especially in sensitive populations such as newborns. This study aimed at determining the impact of the implementation of a computerized physician order entry (CPOE) system on PN medication errors in the neonatology department in the largest teaching hospital in Tunisia. Materiel & Methods: The frequency of medication errors in PN, in a teaching neonatal intensive care unit, was prospectively reviewed by a pharmacist between December 2018 and March 2019 in a two-phase interventional study (pre and post locally developed CPOE System implementation). RESULTS Implementation of CPOE system decreased PN order errors from 379 to 147 representing a 61.1% reduction. The decreases on PN order errors per stage, i.e. prescribing and preparation, were form 207 to 22 (89.4%), and from 117 to 66 (43.6%) respectively. Mean nutrients intakes were in conformity to the recommended daily intakes during the CPOE phase of the study. CPOE is a protective tool against prescription and preparation errors. It significantly impacted all items of the ordering process. CONCLUSIONS In addition to the rigorous application of the recommendations, the CPOE system allows to reduce the risk of PN medication errors. This improves the safety and quality of medicines in newborns.
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Affiliation(s)
- A Abbassi
- Department of Pharmacy, Charle-Nicolle Hospital, 1006 Tunis, Tunisia.
| | - N Hasni
- College of Pharmacy, 5000 Monastir, Tunisia.
| | - E B Ben Hamida
- Neonatal intensive care unit, Charles-Nicolle Hospital, 1006 Tunis, Tunisia.
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Luri M, Leache L, Gastaminza G, Idoate A, Ortega A. A systematic review of drug allergy alert systems. Int J Med Inform 2022; 159:104673. [PMID: 34990941 DOI: 10.1016/j.ijmedinf.2021.104673] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 11/12/2021] [Accepted: 12/20/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND OBJECTIVE Drug allergy alert systems (DAAS), have been considered an effective strategy to reduce preventable adverse drug events (ADEs), improving patient's safety. To date, no review has been conducted analyzing characteristics of DAAS in the hospital setting. Therefore, the aim of this study is to identify, describe and summarize the DAAS used in hospitals. The secondary objectives are to analyse drug allergy alerts (DAA) characteristics, the override rate (OvR) and the clinical consequences of alert overrides. METHODS Searches were conducted in Medline and Cochrane Library to identify studies describing DAAS. Systems characteristics, generated alerts, DAA, OvR, and its clinical consequences were extracted and analyzed. RESULTS Twenty-eight articles were included in the review. Seventeen different electronic DAAS were identified, of which 53% were commercially available. Systems differed in drug allergy information and rules for generating alerts. DAA were generally interruptive, triggered by non-exact match at drug prescribing and when ignored, an override reason was mandatory. The OvR ranged from 43.7% to 97%. The main override reason given by providers was that 'patient had previously tolerated or had taken the drug without allergic reaction'. Clinical consequences of overriding DAA were only analyzed in four studies, with an ADE incidence between 0% and 6%. CONCLUSIONS Different DAAS are used in hospitals with some degree of heterogeneity. Accurate and updated drug allergy information is important to generate only high value alerts. A regular review of DAAS and a standardization of alert rules, alert information and override reasons are necessary to optimize systems. Future studies should evaluate the impact of the DAAS aspects on preventing ADEs.
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Affiliation(s)
- Marta Luri
- Hospital Pharmacy Services, Clínica Universidad de Navarra, Pio XII Avenue 36, Zip code: 31008, Pamplona, Spain.
| | - Leire Leache
- Unit of Innovation and Organization, Navarre Health Service, Tudela Street 20, 1(st) floor, Zip code: 31003, Pamplona, Spain.
| | - Gabriel Gastaminza
- Allergology Department, Clínica Universidad de Navarra, Pio XII Avenue 36, Zip code: 31008, Pamplona, Spain.
| | - Antonio Idoate
- Hospital Pharmacy Services, Clínica Universidad de Navarra, Pio XII Avenue 36, Zip code: 31008, Pamplona, Spain.
| | - Ana Ortega
- Hospital Pharmacy Services, Clínica Universidad de Navarra, Pio XII Avenue 36, Zip code: 31008, Pamplona, Spain.
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50
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Kuo YC, Cheng SH, Chiu HC. Advanced Medication Alert System Decreased Hospital-Based Outpatient Duplicated Medications: A Longitudinal Hospital Cohort Study. J Patient Saf 2022; 18:124-129. [PMID: 35188926 DOI: 10.1097/pts.0000000000000824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES This study aimed to examine the associations between adoption of an advanced medication alert system and decreases in hospital-based outpatient duplicated medication rates in Taiwan. METHODS The unit of analysis was the hospital. We merged the hospital medication alert system adoption survey data and Taiwan National Health Insurance outpatient claims data. The observation time was 1998 to 2011, divided into 5 periods (T1-T5). The analysis included 216 hospitals, and outcome variable was hospital-based outpatient duplicated medication rates. The system adoption time frame, hospital accreditation level, and number of drugs per prescription were defined as predicted variables. A generalized estimating equation regression model was used. RESULTS Adoption of the advanced medication alert system gradually increased, such that 100% of medical centers and 84% of regional hospitals, but less than 50% of district hospitals, had systems by T5. The hospital-based outpatient duplicated medication rate continually decreased, from 29.8% to 11.2%. The generalized estimating equation model showed rates of duplicated medications of b = -8.44 at T2 and b = -17.88 at T5 (P < 0.001) compared with T1. Medical centers and regional hospitals demonstrated much lower duplication rates (b = -13.71, b = -6.82; P < 0.001) compared with district hospitals. Hospitals with more medications per prescription had higher duplication rates than did hospitals with fewer items. CONCLUSIONS Hospitals accredited at higher levels tended to have advanced medication alert systems. Hospitals that implemented advanced systems decreased hospital-based outpatient duplicated medications, avoiding a potential risk due to inappropriate medication use.
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Affiliation(s)
- Yu-Chun Kuo
- From the Health Research Institute, Fujian Medical University, Fuzhou, Fujian, China
| | - Shou-Hsia Cheng
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan
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