Using a computerized provider order entry system to meet the unique prescribing needs of children: description of an advanced dosing model

<p>Abstract</p> <p>Background</p> <p>It is well known that the information requirements necessary to safely treat children with therapeutic medications cannot be met with the same approaches used in adults. Over a 1-year period, Duke University Hospital engaged in the challenging task of enhancing an established computerized provider order entry (CPOE) system to address the unique medication dosing needs of pediatric patients.</p> <p>Methods</p> <p>An advanced dosing model (ADM) was designed to interact with our existing CPOE application to provide decision support enabling complex pediatric dose calculations based on chronological age, gestational age, weight, care area in the hospital, indication, and level of renal impairment. Given that weight is a critical component of medication dosing that may change over time, alerting logic was added to guard against erroneous entry or outdated weight information.</p> <p>Results</p> <p>Pediatric CPOE was deployed in a staggered fashion across 6 care areas over a 14-month period. Safeguards to prevent miskeyed values became important in allowing providers the flexibility to override the ADM logic if desired. Methods to guard against over- and under-dosing were added. The modular nature of our model allows us to easily add new dosing scenarios for specialized populations as the pediatric population and formulary change over time.</p> <p>Conclusions</p> <p>The medical needs of pediatric patients vary greatly from those of adults, and the information systems that support those needs require tailored approaches to design and implementation. When a single CPOE system is used for both adults and pediatrics, safeguards such as redirection and suppression must be used to protect children from inappropriate adult medication dosing content. Unlike other pediatric dosing systems, our model provides active dosing assistance and dosing process management, not just static dosing advice.</p

A review of human factors principles for the design and implementation of medication safety alerts in clinical information systems.

The objective of this review is to describe the implementation of human factors principles for the design of alerts in clinical information systems. First, we conduct a review of alarm systems to identify human factors principles that are employed in the design and implementation of alerts. Second, we review the medical informatics literature to provide examples of the implementation of human factors principles in current clinical information systems using alerts to provide medication decision support. Last, we suggest actionable recommendations for delivering effective clinical decision support using alerts. A review of studies from the medical informatics literature suggests that many basic human factors principles are not followed, possibly contributing to the lack of acceptance of alerts in clinical information systems. We evaluate the limitations of current alerting philosophies and provide recommendations for improving acceptance of alerts by incorporating human factors principles in their design

Intervention Component Analysis (ICA): a pragmatic approach for identifying the critical features of complex interventions

Background: In order to enable replication of effective complex interventions, systematic reviews need to provide evidence about their critical features and clear procedural details for their implementation. Currently, few systematic reviews provide sufficient guidance of this sort. / Methods: Through a worked example, this paper reports on a methodological approach, Intervention Component Analysis (ICA), specifically developed to bridge the gap between evidence of effectiveness and practical implementation of interventions. By (a) using an inductive approach to explore the nature of intervention features and (b) making use of trialists’ informally reported experience-based evidence, the approach is designed to overcome the deficiencies of poor reporting which often hinders knowledge translation work whilst also avoiding the need to invest significant amounts of time and resources in following up details with authors. / Results: A key strength of the approach is its ability to reveal hidden or overlooked intervention features and barriers and facilitators only identified in practical application of interventions. It is thus especially useful where hypothesised mechanisms in an existing programme theory have failed. A further benefit of the approach is its ability to identify potentially new configurations of components that have not yet been evaluated. / Conclusions: ICA is a formal and rigorous yet relatively streamlined approach to identify key intervention content and implementation processes. ICA addresses a critical need for knowledge translation around complex interventions to support policy decisions and evidence implementation

Association of Electronic Health Records with Methicillin-Resistant Staphylococcus aureus Infection in a National Sample

This study examined the relationship between advanced electronic health record (EHR) use in hospitals and rates of Methicillin-resistant Staphylococcus aureus (MRSA) infection in an inpatient setting. National Inpatient Sample (NIS) and Health Information Management Systems Society (HIMSS) Annual Survey are combined in the retrospective, cross-sectional analysis. A twenty percent simple random sample of the combined 2009 NIS and HIMSS datasets included a total of 1,032,905 patient cases of MRSA in 550 hospitals. Results of the propensity-adjusted logistic regression model revealed a statistically significant association between advanced EHR and MRSA, with patient cases from an advanced EHR being less likely to report a MRSA diagnosis code

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

Pharmacy Manager System Implementation Strategies to Mitigate the Cost of Prescription Errors

AbstractOne of the most frequent medical errors in contemporary medicine is incorrect prescriptions, and the profits from retail pharmacy operations are adversely impacted by the costs associated with prescription errors. Independent pharmacy managers are interested in finding workable strategies to mitigate the cost of prescription errors and increase profit. Using the resource-based theory of competitive advantage (RBTCA), the purpose of this qualitative multiple-case study was to explore strategies some independent pharmacy managers in Texas use to mitigate the cost of pharmacy employee prescription errors and increase profitability. The participants were five independent pharmacy managers who implemented strategies to mitigate the cost of prescription errors. Data were collected using semistructured, face-to-face interviews, a review of company documents, and site observation notes. Through thematic analysis, four themes emerged: (a) cost of prescription quality check and errors reduction strategy, (b) increased profitability strategy through error cost mitigation, (c) positive utilization of organization resources strategy, and (d) technology system implementation strategy to reduce prescription errors. A key recommendation is for independent pharmacy managers to involve pharmacy staff in developing the pharmacy system to promote user acceptance, which will assist in reducing prescription errors and raising profit. The implications for positive social change include the potential to mitigate the cost of prescription errors, prevent hospitalization and fatalities caused by medication errors, enhance patients’ quality of life, and boost the economy and employment opportunities in their communities

Preconceived Physician Attitude Toward Computerized Physician Order Entry (CPOE): Implications for Successful Implementation

There has been a societal and legislative push to implement computerized physician order entry (CPOE) systems throughout hospitals nationally in recent years due in large part to the public\u27s awareness of an inordinate number of patient deaths due to medication errors in hospital settings. This mortality, and untold morbidity, became even more unacceptable when published findings suggested the majority of these 100,000 deaths each year could be avoided through the use of CPOE systems. Yet acceptance has been slow and only a fraction of the hospitals have implemented this technology due to large start up costs, enormous technological requirements, and prior well-published failures of such attempts largely due to physicians\u27 lack of acceptance. A total of71 participants were surveyed whose daily responsibility involved the ordering of medications, to determine what attitudes they had concerning CPOE systems. This was done at a facility scheduled to implement such a system over the next year. The data showed evidence supporting many of the current implementation strategies, while suggesting modification of others. Based on these findings, recommendations are made for future implementations with the hope of gaining enhanced physician acceptance and adoption, facilitating a more successful implementation of CPOE systems

Pharmacy Manager System Implementation Strategies to Mitigate the Cost of Prescription Errors

AbstractOne of the most frequent medical errors in contemporary medicine is incorrect prescriptions, and the profits from retail pharmacy operations are adversely impacted by the costs associated with prescription errors. Independent pharmacy managers are interested in finding workable strategies to mitigate the cost of prescription errors and increase profit. Using the resource-based theory of competitive advantage (RBTCA), the purpose of this qualitative multiple-case study was to explore strategies some independent pharmacy managers in Texas use to mitigate the cost of pharmacy employee prescription errors and increase profitability. The participants were five independent pharmacy managers who implemented strategies to mitigate the cost of prescription errors. Data were collected using semistructured, face-to-face interviews, a review of company documents, and site observation notes. Through thematic analysis, four themes emerged: (a) cost of prescription quality check and errors reduction strategy, (b) increased profitability strategy through error cost mitigation, (c) positive utilization of organization resources strategy, and (d) technology system implementation strategy to reduce prescription errors. A key recommendation is for independent pharmacy managers to involve pharmacy staff in developing the pharmacy system to promote user acceptance, which will assist in reducing prescription errors and raising profit. The implications for positive social change include the potential to mitigate the cost of prescription errors, prevent hospitalization and fatalities caused by medication errors, enhance patients’ quality of life, and boost the economy and employment opportunities in their communities

Process Improvement to Reduce Route of Medication Administration Errors in Patients with Enteral Feeding Tubes

Advances in health information management in the form electronic health records, computerized provider order entry systems, and clinical decision support systems and tools have enhanced the productivity, effectiveness, and efficiency of healthcare. However, the cost of these positive effects does come at the expense of other factors. Along with the introduction of Clinical Provider Order Entry (CPOE) systems, organizations have experienced new possibilities for medication errors and risks to patient safety. Factors associated with these errors should be evaluated in detail in order to mitigate the causes of these types of errors and to plan strategies for prevention. Continued research into how to improve the quality of these systems is necessary to promote the usability and acceptance of CPOE systems by prescribers and to continue to make an impact on the frequency of medication errors within health care organizations. Health care organizations must develop strategies to improve the rate of medication errors caused by CPOE systems. Strategies may vary from organization to organization, and depend upon organization-specific resources. Ideally, a plan to improve patient safety and prevent errors related to CPOE systems would include stakeholders such as the clinical team and providers, involve a system that can audit the frequency of errors, and include ongoing education about the problem and the proposed solution. A plan to prevent errors and improve patient safety that is not-dependent upon the intricacies of a specific electronic medical record is ideal. A strategy that can carry-over from one electronic medical record system to the next and that can address the central problem with accuracy, efficiency, and evidence-based research will be proposed