How the presentation of patient information and decision-support advisories influences opioid prescribing behavior: A simulation study

ObjectiveThe United States faces an opioid crisis. Integrating prescription drug monitoring programs into electronic health records offers promise to improve opioid prescribing practices. This study aimed to evaluate 2 different user interface designs for prescription drug monitoring program and electronic health record integration.Materials and MethodsTwenty-four resident physicians participated in a randomized controlled experiment using 4 simulated patient cases. In the conventional condition, prescription opioid histories were presented in tabular format, and computerized clinical decision support (CDS) was provided via interruptive modal dialogs (ie, pop-ups). The alternative condition featured a graphical opioid history, a cue to visit that history, and noninterruptive CDS. Two attending pain specialists judged prescription appropriateness.ResultsParticipants in the alternative condition wrote more appropriate prescriptions. When asked after the experiment, most participants stated that they preferred the alternative design to the conventional design.ConclusionsHow patient information and CDS are presented appears to have a significant influence on opioid prescribing behavior

An investigation of healthcare professionals’ experiences of training and using electronic prescribing systems: four literature reviews and two qualitative studies undertaken in the UK hospital context

Electronic prescribing (ePrescribing) is the process of ordering medicines electronically for a patient and has been associated with reduced medication errors and improved patient safety. However, these systems have also been associated with unintended adverse consequences. There is a lack of published research about users’ experiences of these systems in UK hospitals. The aim of this research was therefore to firstly describe the literature pertaining to the recent developments and persisting issues with ePrescribing and clinical decision support systems (CDS) (chapter 2). Two further systematic literature reviews (chapters 3 and 4) were then conducted to understand the unintended consequences of ePrescribing and clinical decision support (CDS) systems across both adult and paediatric patients. These revealed a taxonomy of factors, which have contributed to errors during use of these systems e.g., the screen layout, default settings and inappropriate drug-dosage support. The researcher then conducted a qualitative study (chapters 7-10) to explore users’ experiences of using and being trained to use ePrescribing systems. This study involved conducting semi-structured interviews and observations, which revealed key challenges facing users, including issues with using the ‘Medication List’ and how information was presented. Users experienced benefits and challenges when customising the system, including the screen display; however, the process was sometimes overly complex. Users also described the benefits and challenges associated with different forms of interruptive and passive CDS. Order sets, for instance, encouraged more efficient prescribing, yet users often found them difficult to find within the system. A lack of training resulted in users failing to use all features of the ePrescribing system and left some healthcare staff feeling underprepared for using the system in their role. A further literature review (chapter 5) was then performed to complement emerging themes relating to how users were trained to use ePrescribing systems, which were generated as part of a qualitative study. This review revealed the range of approaches used to train users and the need for further research in this area. The literature review and qualitative study-based findings led to a follow-on study (chapter 10), whereby the researcher conducted semi-structured interviews to examine how users were trained to use ePrescribing systems across four NHS Hospital Trusts. A range of approaches were used to train users; tailored training, using clinically specific scenarios or matching the user’s profession to that of the trainer were preferred over lectures and e-learning may offer an efficient way of training large numbers of staff. However, further research is needed to investigate this and whether alternative approaches such as the use of students as trainers could be useful. This programme of work revealed the importance of human factors and user involvement in the design and ongoing development of ePrescribing systems. Training also played a role in users’ experiences of using the system and hospitals should carefully consider the training approaches used. This thesis provides recommendations gathered from the literature and primary data collection that can help inform organisations, system developers and further research in this area

Systematic review of the safety of medication use in inpatient, outpatient and primary care settings in the Gulf Cooperation Council countries

Background Errors in medication use are a patient safety concern globally, with different regions reporting differing error rates, causes of errors and proposed solutions. The objectives of this review were to identify, summarise, review and evaluate published studies on medication errors, drug related problems and adverse drug events in the Gulf Cooperation Council (GCC) countries. Methods A systematic review was carried out using six databases, searching for literature published between January 1990 and August 2016. Research articles focussing on medication errors, drug related problems or adverse drug events within different healthcare settings in the GCC were included. Results Of 2094 records screened, 54 studies met our inclusion criteria. Kuwait was the only GCC country with no studies included. Prescribing errors were reported to be as high as 91% of a sample of primary care prescriptions analysed in one study. Of drug-related admissions evaluated in the emergency department the most common reason was patient non-compliance. In the inpatient care setting, a study of review of patient charts and medication orders identified prescribing errors in 7% of medication orders, another reported prescribing errors present in 56% of medication orders. The majority of drug related problems identified in inpatient paediatric wards were judged to be preventable. Adverse drug events were reported to occur in 8.5–16.9 per 100 admissions with up to 30% judged preventable, with occurrence being highest in the intensive care unit. Dosing errors were common in inpatient, outpatient and primary care settings. Omission of the administered dose as well as omission of prescribed medication at medication reconciliation were common. Studies of pharmacists’ interventions in clinical practice reported a varying level of acceptance, ranging from 53% to 98% of pharmacists’ recommendations. Conclusions Studies of medication errors, drug related problems and adverse drug events are increasing in the GCC. However, variation in methods, definitions and denominators preclude calculation of an overall error rate. Research with more robust methodologies and longer follow up periods is now required.Peer reviewe

Impact of computerized physician order entry on medication prescription errors in the intensive care unit: a controlled cross-sectional trial

INTRODUCTION: Medication errors in the intensive care unit (ICU) are frequent and lead to attributable patient morbidity and mortality, increased length of ICU stay and substantial extra costs. We investigated if the introduction of a computerized ICU system (Centricity Critical Care Clinisoft, GE Healthcare) reduced the incidence and severity of medication prescription errors (MPEs). METHODS: A prospective trial was conducted in a paper-based unit (PB-U) versus a computerized unit (C-U) in a 22-bed ICU of a tertiary university hospital. Every medication order and medication prescription error was validated by a clinical pharmacist. The registration of different classes of MPE was done according to the National Coordinating Council for Medication Error Reporting and Prevention guidelines. An independent panel evaluated the severity of MPEs. We identified three groups: minor MPEs (no potential to cause harm); intercepted MPEs (potential to cause harm but intercepted on time); and serious MPEs (non-intercepted potential adverse drug events (ADE) or ADEs, being MPEs with potential to cause, or actually causing, patient harm). RESULTS: The C-U and the PB-U each contained 80 patient-days, and a total of 2,510 medication prescriptions were evaluated. The clinical pharmacist identified 375 MPEs. The incidence of MPEs was significantly lower in the C-U compared with the PB-U (44/1286 (3.4%) versus 331/1224 (27.0%); P < 0.001). There were significantly less minor MPEs in the C-U than in the PB-U (9 versus 225; P < 0.001). Intercepted MPEs were also lower in the C-U (12 versus 46; P < 0.001), as well as the non-intercepted potential ADEs (21 versus 48; P < 0.001). There was also a reduction of ADEs (2 in the C-U versus 12 in the PB-U; P < 0.01). No fatal errors occurred. The most frequent drug classes involved were cardiovascular medication and antibiotics in both groups. Patients with renal failure experienced less dosing errors in the C-U versus the PB-U (12 versus 35 serious MPEs; P < 0.001). CONCLUSION: The ICU computerization, including the medication order entry, resulted in a significant decrease in the occurrence and severity of medication errors in the ICU

Impact of an Electronic Medical Record Implementation on Drug Allergy Overrides in a Large Southeastern HMO Setting

Renny Varghese Impact of an Electronic Medical Record Implementation on Drug Allergy Overrides in a Large Southeastern HMO Setting (Under the direction of Russell Toal, Associate Professor) Electronic medical records (EMRs) have become recognized as an important tool for improving patient safety and quality of care. Decision support tools such as alerting functions for patient medication allergies are a key part of reducing the frequency of serious medication problems. Kaiser Permanente Georgia (KPGA) implemented its EMR system in the primary care departments at Kaiser\u27s twelve facilities in the greater metro Atlanta area over a six month period beginning in June 2005 and ending December 2005. The aim of this study is to analyze the impact of the EMR implementation on the number of drug allergy overrides within this large HMO outpatient setting. Research was conducted by comparing the rate of drug allergy overrides during pre and post EMR implementation. The timeline will be six months pre and post implementation. Observing the impact of the incidence rate of drug allergy alerts after the implementation provided insight into the effectiveness of EMRs in reducing contraindicated drug allergies. Results show that the incidence rate of drug allergy overrides per 1,000 filled prescriptions rose by a statistically significant 5.9% (ñ \u3e 0.0002; 95% CI [-1.531, -0.767]) following the implementation. Although results were unexpected, several factors are discussed as to the reason for the increase. Further research is recommended to explore trends in provider behavior, KPGA specific facilities and departments, and in other KP regions and non-KP healthcare settings. INDEX WORDS: electronic medical records, drug allergy overrides, patient safety, medication errors, decision support tools, outpatient setting, primary care, computerized provider order entr

Factors Associated with Ordering and Completion of Laboratory Monitoring Tests for High-Risk Medications in the Ambulatory Setting: A Dissertation

Since the Institute of Medicine highlighted the devastating impact of medical errors in their seminal report, “To Err is Human” (2000), efforts have been underway to improve patient safety. A portion of medical errors are due to medication errors, and a large portion of these can be attributed to inadequate laboratory monitoring. In this thesis, I attempt to address this small but important corner of this patient safety endeavor. Why are patients not getting their laboratory monitoring tests? Do they fail to complete them or do doctors not order the tests in the first place? Which prescribers and which patients are least likely to do what is needed for testing to happen and what interventions would be most promising? To address these questions, I conducted a systematic review of existing interventions. I then proceeded with three aims: 1) To identify reasons that patients give for missing monitoring tests; 2) To identify patient and provider factors associated with monitoring test ordering; and 3) To identify patient and provider factors associated with completion of ordered testing. To achieve these aims, I worked with patients and data at the Fallon Clinic. For aim 1, I conducted a qualitative analysis of their reasons for missing tests as well as reporting completion and ordering rates. For aims 2 and 3, I used electronic medical record data and conducted a regression with patient and provider characteristics as covariates to identify factors contributing to test ordering and completion. Interviews revealed that patients had few barriers to completion, with forgetting being the most common reason for missing a test. The quantitative studies showed that: older patients with more interactions with the health care system were more likely to have tests ordered and were more likely to complete them; providers who more frequently prescribe a drug were more likely to order testing for it; and drug-test combinations that were particularly dangerous, indicated by a black box warning, were more likely to have appropriate ordering, though for these combinations, primary care providers were less likely to order tests appropriately, and patients were less likely to complete tests. Taken together, my work can inform future interventions in laboratory monitoring and patient safety

체계적 문헌고찰과 메타분석을 통한 전산처방자동화시스템과 관련된 처방오류 평가 연구

학위논문 (석사) -- 서울대학교 대학원 : 약학대학 약학과, 2020. 8. 김은경.Computerized Physician Order Entry (CPOE) systems and Clinical Decision Support Systems (CDSS) have been proven to contribute to improve patients safety and quality of care; however, the adoption of computerization introduced a new type of error, called system-related or technology-induced errors. A comprehensive evaluation regarding the prevalence of CPOE-related errors (CRE) is lacking. The aim of this study was to describe the prevalence of CRE evaluated by pharmacists and to evaluate the association between the introduction of CPOE and prescribing errors. A systematic review and meta-analysis were conducted of studies retrieved from the MEDLINE, Embase, Cochrane, and Scopus up to March 2020. All studies reporting the rate of prescribing errors related to CPOE were included. The prevalence of CRE among overall prescribing errors occurred in the hospitals was estimated using pooled prevalence estimate with a 95% confidence interval (CI) and relative risk (RR) was calculated for the subgroup analysis. A total of 14 studies were identified and included in the systematic review and meta-analysis. In the meta-analysis of 13 data of estimate, the overall pooled prevalence of CRE across studies were 32.36% (95% CI 22.87 – 42.62). Among the 6 types of error identified throughout the studies: omission, wrong drug, wrong dose, wrong route/form, wrong time, and monitoring error, the main type of error related to CPOE were wrong dose (47.28%, 95% CI 38.38-56.26), followed by wrong drug (14.45%, 95% CI 7.96-22.40). The subgroup analysis revealed that the risk of error was not significantly reduced with CPOE (RR 0.842, 95% CI 0.559 – 1.268), except omission which was significantly reduced after the implementation of CPOE (RR 0.484, 95% CI 0.282 – 0.831). Our study findings support that system-related errors were a major reason for CPOE not delivering a significant reduction in the overall rate of clinical errors. A considerable risk for prescribing errors still exists, which healthcare professionals should be aware that CPOE could also lead to a new type of medication errors. In order to reduce the prescribing error related to CPOE, the system should be continually examined and users should receive periodic and multidisciplinary training on the use of CPOE and CDSS.처방자동화시스템(Computerized Physician Order Entry, CPOE)과 임상의사결정지원시스템(Clinical Decision Support System)의 활성화로 전체적인 처방오류의 비율은 감소하였지만, CPOE와 같은 새로운 시스템으로 인하여 새로운 오류가 출현되었다. 본 연구는 원내 CPOE와 관련된 약물 처방오류 중 약사가 평가한 처방오류의 발생률과 CPOE 도입 전후 오류유형의 변화를 파악하고자 선행연구들을 대상으로 체계적 문헌고찰과 메타분석을 수행하였다. PubMed, EMBASE, Cochrane Register of Controlled Trials, Scopus에서 2020년 3월까지 검색되는 문헌 중 CPOE 도입 후 발생한 처방오류에 해당하는 문헌을 추출하였고 선정 및 제외기준에 따라 총 14개의 최종 문헌을 선정하였다. 처방오류의 합동 발생률 수치와 CPOE 도입 전과 후 유형 별 처방오류 발생의 상대 위험도 및 95% 신뢰 구간은 랜덤 효과 모델을 적용하여 제시하였다. CPOE 도입 후 전체 처방오류 중 CPOE로 인한 처방오류의 발생률 추정치 범위는 12.78%에서 58.54% 사이였고 랜덤 효과 모델에서 계산된 합동 발생률은 32.36%였다 (95% 신뢰 구간 22.87-42.62). National Coordinating Council for Medication Error Reporting and Prevention 분류체계에 기반하여 문헌에서 추출 가능한 처방오류의 유형을 처방 누락오류, 약물 오류, 용량오류, 제형 및 투여경로 오류, 투여 시간 오류, 약물 모니터링과 같이 총 6개 유형으로 분류하였을 때, 용량오류가 47.28% (95% 신뢰 구간 38.38-56.26)로 가장 높았고 그 다음은 약물 오류가 14.45% (95% 신뢰 구간 7.96-22.40)으로 높았다. CPOE 도입 전과 후의 처방오류 유형별 발생을 비교하기 위하여 하위그룹 메타 분석을 하였을 때, CPOE 도입 후 전체적인 처방오류의 발생률은 CPOE 도입 전에 비해 통계적으로 유의하게 증가하지 않았으나 (Relative risk, RR 0.842, 95% 신뢰 구간 0.559-1.168), 6개 처방오류 유형 중 메타분석이 가능한 5개 오류 유형 중 (처방 누락오류, 약물 오류, 용량오류, 제형 및 투여경로 오류, 약물 모니터링) 처방 누락오류만 CPOE 도입 후 유의하게 줄어들었다 (RR 0.484, 95% 신뢰 구간 0.282-0.831). 체계적 문헌고찰 및 메타분석을 통해 새로운 기술인 CPOE 도입 후 CPOE와 관련된 처방오류가 전체 처방오류 중 1/3의 빈도로 발생하는 것으로 파악되었다. 처방오류의 유형 중 처방 누락오류, 약물 오류, 용량오류, 제형 및 투여경로 오류, 약물 모니터링의 오류의 발생 비율은 CPOE 도입 전과 후에 유의한 변화를 보이지 않았으나, 처방 누락의 비율은 CPOE 도입 후에 낮아진 것으로 나타났다. 약물처방의 전자화와 처방 지원 시스템과 같은 새로운 기술의 도입으로 단순 실수로 인한 처방오류는 방지되었으나 다양한 처방오류가 지속해서 발생함으로 환자의 안전을 위한 시스템 사용자의 지속적인 교육과 시스템의 기술적 개선으로 처방오류의 예방, 감지, 및 모니터링의 노력이 필요하다.1. Introduction 1 2. Methods 3 3. Results 8 4. Discussion 25 5. Conclusion 31 References 32 Appendix 40 요약 (국문초록) 48Maste