Indication Alerts Intercept Drug Name Confusion Errors during Computerized Entry of Medication Orders

Background: Confusion between similar drug names is a common cause of potentially harmful medication errors. Interventions to prevent these errors at the point of prescribing have had limited success. The purpose of this study is to measure whether indication alerts at the time of computerized physician order entry (CPOE) can intercept drug name confusion errors. Methods and Findings: A retrospective observational study of alerts provided to prescribers in a public, tertiary hospital and ambulatory practice with medication orders placed using CPOE. Consecutive patients seen from April 2006 through February 2012 were eligible if a clinician received an indication alert during ordering. A total of 54,499 unique patients were included. The computerized decision support system prompted prescribers to enter indications when certain medications were ordered without a coded indication in the electronic problem list. Alerts required prescribers either to ignore them by clicking OK, to place a problem in the problem list, or to cancel the order. Main outcome was the proportion of indication alerts resulting in the interception of drug name confusion errors. Error interception was determined using an algorithm to identify instances in which an alert triggered, the initial medication order was not completed, and the same prescriber ordered a similar-sounding medication on the same patient within 5 minutes. Similarity was defined using standard text similarity measures. Two clinicians performed chart review of all cases to determine whether the first, non-completed medication order had a documented or non-documented, plausible indication for use. If either reviewer found a plausible indication, the case was not considered an error. We analyzed 127,458 alerts and identified 176 intercepted drug name confusion errors, an interception rate of 0.14±.01%. Conclusions: Indication alerts intercepted 1.4 drug name confusion errors per 1000 alerts. Institutions with CPOE should consider using indication prompts to intercept drug name confusion errors

Indication documentation and indication-based prescribing within electronic prescribing systems: a systematic review and narrative synthesis

BACKGROUND: Despite recommendations, documentation of indication on prescriptions and inpatient medication orders is not routinely practised. There has been a recent systematic review of indication documentation for antimicrobials, but not for interventions relating to indication documentation for medication more broadly. Our aims were to 1) identify, describe and synthesise the literature relating to effectiveness of interventions aimed at improving indication documentation and/or indication-based prescribing in both primary and secondary healthcare; 2) synthesise participant perspectives to identify barriers and facilitators to these interventions; and 3) make recommendations for both practice and research. METHODS: A systematic literature search was conducted using Medline, Embase and CINAHL using two search concepts: electronic prescribing systems, and indication documentation and/or indication-based prescribing. Qualitative, quantitative and mixed-methods studies were included; outcome measures and results were extracted to produce a narrative synthesis. Quality appraisal by two independent reviewers was undertaken using the Mixed Methods Appraisal Tool. RESULTS: We identified 21 studies evaluating interventions to aid indication documentation. Indication documentation was either via free-text, selection from a list, or by use of pre-defined indication-based order sentences for individual medications. For a number of outcomes, there was a mostly positive impact, including appropriateness of the medication order (6 of 8 studies), rates of prescribing error (2/2) and some less commonly reported clinical (2/4) and workflow-related outcomes (2/3). There was a less favourable impact on accuracy of indication documentation and rates of medication use, highlighting some unintended consequences that may occur when implementing new interventions. Participant insights from prescribers and other healthcare professionals complemented quantitative study results, highlighting both facilitators and barriers to indication documentation and the associated interventions. For example, barriers included long drop-down lists and the need to use workarounds to navigate approval systems due to time or knowledge constraints. Facilitating factors included the perceived benefits of indication documentation on communication among the healthcare team and with the patient. CONCLUSION: Indication documentation has the potential to improve appropriate prescribing and reduce prescribing errors. However, further benefits to the prescriber, multidisciplinary team and patient may only be realised by developing methods of indication documentation that integrate more efficiently with prescriber workflows. PROSPERO REGISTRATION NUMBER: CRD42021278495

EVALUATING PATIENT MEDICATION AND COMPLEMENTARY THERAPIES DOCUMENTATION: COMPARATIVE ANALYSIS OF SOURCES, DISCREPANCIES AND THE POTENTIAL IMPACT OF ERRORS ON PATIENT CARE

Complete knowledge of a patient's medications, including over-the-counter and alternative medicines, is essential to the healthcare professional in providing quality care. In addition to the multiple steps from prescribing, dispensing to administering of a drug medication, there are several factors that increase an individual's risk for an adverse event and approaches to reduce medication errors. The movement of healthcare systems to an electronic medical record provides the potential of building a better health care system. This retrospective study compares five sources of medication, medical record chart, specialist, electronic medical record, pharmacy, insurance provider and patient, to determine what is the most accurate source of documentation, and what factors leading to better knowledge and documentation of all of a patient's medications. This study also identifies additional risk factors, specifically drug affordability and the influence it has on a patient's behavior, and discusses some considerations for reducing medication errors. The prevention and reduction of adverse events is of public health significance as there is both a health and financial cost to treating these adverse events

Implementation of Hypertension Clinical Practice Guidelines: A Systematic Review of Strategies to Change Physician Behavior and Improve Patient Outcomes

Background: Hypertension remains a major cause of cardiovascular disease morbidity and mortality worldwide. There is strong evidence that blood pressure control is associated with significant reduction in morbidity and mortality caused by cardiovascular events. However, only one-third of Americans with hypertension have adequate blood pressure control. Clinical practice guidelines have been established to guide physician treatment of hypertension, yet many physicians do not follow these guidelines. In response to this problem, there is a growing body of literature regarding interventions designed to help physicians adhere to hypertension clinical practice guidelines. Objectives: To systematically identify, appraise and synthesize studies of professional educational or quality assurance interventions designed to improve physician adherence to hypertension clinical practice guidelines. The effectiveness of various intervention strategies in changing physician behavior and improving patient outcomes will be evaluated. Research design: I performed a systematic review of studies published in MEDLINE between 1966 and 2005 describing interventions to improve physician adherence to hypertension guidelines in primary care. Randomized controlled trials, cohort studies, case control studies and time-series analyses describing physician targeted educational or quality assurance interventions with objective measures of physician hypertension management behavior or patient blood pressure outcomes were included. Data from each study was abstracted in to evidence tables for review and all studies were assigned a quality grade based (good, fair, poor) based on their study design and potential for selection bias, measurement bias, and confounding. Results: The initial Medline search yielded 574 citations of which 32 were included in this review. Three citations additional were identified through manual searching, These studies examined the following interventions: educational outreach (n=12), local opinion leaders (n=5), audit and feedback (n=16), decision support (n=5), reminders (n=11), and local consensus development (n=4). Interventions involving Educational Outreach, especially when combined with Local Opinion Leader and Audit and Feedback, resulted in moderate changes in prescribing behavior and small increases in blood pressure control. No studies examined the independent effects of educational outreach or local opinion leaders, but audit and feedback appeared to have no effect on its own. Interventions involving Reminders were highly effective in increasing screening and prescribing, but did not reduce blood pressure; while decision support was generally ineffective on its own. Local Consensus Development of Guidelines had moderate to large effects on prescribing behavior and had mixed results on blood pressure control. Conclusions: No single educational or quality assurance intervention is superior to others in improving physician adherence to hypertension guidelines, although several interventions appear to be ineffective or untested on their own. Multifaceted Interventions especially those involving Educational Outreach by Local Opinion Leaders, Audit and Feedback, Local Consensus Guideline Development and/or Reminders appear to be the most promising physician oriented interventions to improve patient blood pressure control.Master of Public Healt

Determinants of a successful problem list to support the implementation of the problem-oriented medical record according to recent literature

Background: A problem-oriented approach is one of the possibilities to organize a medical record. The problem-oriented medical record (POMR) - a structured organization of patient information per presented medical problem- was introduced at the end of the sixties by Dr. Lawrence Weed to aid dealing with the multiplicity of patient problems. The problem list as a precondition is the centerpiece of the problem-oriented medical record (POMR) also called problem-oriented record (POR). Prior to the digital era, paper records presented a flat list of medical problems to the healthcare professional without the features that are possible with current technology. In modern EHRs a POMR based on a structured problem list can be used for clinical decision support, registries, order management, population health, and potentially other innovative functionality in the future, thereby providing a new incentive to the implementation and use of the POMR. Methods: On both 12 May 2014 and 1 June 2015 a systematic literature search was conducted. From the retrieved articles statements regarding the POMR and related to successful or non-successful implementation, were categorized. Generic determinants were extracted from these statements. Results: In this research 38 articles were included. The literature analysis led to 12 generic determinants: clinical practice/reasoning, complete and accurate problem list, data structure/content, efficiency, functionality, interoperability, multi-disciplinary, overview of patient information, quality of care

Identifying and reducing inappropriate use of medications using Electronic Health Records

Inappropriate use of medications (IUM) is a global problem that can lead to unnecessary harm to the patients and unnecessary costs across the health care system. Identifying and reducing IUM has been a long-lasting challenge and currently, no systematic and automated solution exists to address it. IUM can be manually identified by experts using medication appropriateness criteria (MAC). In this research I first conducted a review of approaches used to identify IUM and reduce IUM. Next, I developed a conceptual model for representing the MAC, and then developed a tool and a workflow for translating the MAC into structured form. Because indications are an important component of the MAC, I conducted a critical appraisal of existing knowledge sources that can be used to that end, namely the medication-indication knowledge-bases. Finally, I demonstrated how these structured MAC can be used to identify patients who are potentially subject to IUM and evaluated the accuracy of this approach. This research identifies the knowledge gaps and technological challenges in identifying and reducing IUM and addresses some of these gaps through the creation of a representation for MAC, a repository of structured MAC, and a set of tools that can assist in evaluating the impact of interventions aimed to reduce IUM or assess its downstream effects. This research also discusses the limitations of existing methods for executing computable decision support rules and proposes solutions needed to enhance these methods so they can support implementation of the MAC

COMBINING HUMAN FACTORS AND DATA SCIENCE METHODS TO EVALUATE THE USE OF FREE TEXT COMMUNICATION ORDERS IN ELECTRONIC HEALTH RECORDS

Medication errors are a leading cause of death in the United States. Electronic Health Records (EHR) along with Computerized Provider Order Entry (CPOE) are considered promising ways to reduce these errors. However, EHR systems have not eliminated medication errors. Moreover, in some cases they have facilitated errors due to issues such as poor usability and negative effects on clinical workflows. The use of unexpected free text within a CPOE system can serve as a marker that the system does not adequately support clinical workflow. Prior studies have looked at the use of free text within medication orders, but the inclusion of medication related information in communication for non-medication orders (CNMOs), a type of free text order, has not been adequately studied. This mixed-methods study identified the prevalence, nature and reasons for the inclusion of medication related information in CNMOs using a large sample of CNMOs placed at a mid-Atlantic hospital system in 2017, and via interviews with physicians. The study found that more than 42% of CNMOs contain medication related information. Moreover, the use of CNMOs varied significantly across provider types, hospital locations, patient settings and other factors. The study found 10 themes that might cause providers to adopt such workarounds, including missing functionality and poor usability. The viii study also identified several general challenges in communicating medication information in the EHR, and potential solutions to mitigate these challenges. This dissertation also demonstrates how natural language processing could be used to identify medication related CNMOs