A Systematic Review Of The Types And Causes Of Prescribing Errors Generated From Using Computerized Provider Order Entry Systems in Primary and Secondary Care

Objective To understand the different types and causes of prescribing errors associated with computerized provider order entry (CPOE) systems, and recommend improvements in these systems. Materials and Methods We conducted a systematic review of the literature published between January 2004 and June 2015 using three large databases: the Cumulative Index to Nursing and Allied Health Literature, Embase, and Medline. Studies that reported qualitative data about the types and causes of these errors were included. A narrative synthesis of all eligible studies was undertaken. Results A total of 1185 publications were identified, of which 34 were included in the review. We identified 8 key themes associated with CPOE-related prescribing errors: computer screen display, drop-down menus and auto-population, wording, default settings, nonintuitive or inflexible ordering, repeat prescriptions and automated processes, users’ work processes, and clinical decision support systems. Displaying an incomplete list of a patient’s medications on the computer screen often contributed to prescribing errors. Lack of system flexibility resulted in users employing error-prone workarounds, such as the addition of contradictory free-text comments. Users’ misinterpretations of how text was presented in CPOE systems were also linked with the occurrence of prescribing errors. Discussion and Conclusions Human factors design is important to reduce error rates. Drop-down menus should be designed with safeguards to decrease the likelihood of selection errors. Development of more sophisticated clinical decision support, which can perform checks on free-text, may also prevent errors. Further research is needed to ensure that systems minimize error likelihood and meet users’ workflow expectations

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

Electronic Prescribing In Children (EPIC): an evaluation of implementation at a children’s hospital.

Medication errors are common and can cause significant mortality and morbidity. Electronic prescribing (EP), with or without clinical decision support systems (CDSS), is a complex intervention that has been proposed as a solution. US studies indicate that there may be a reduction in medication errors as well as adverse events, but equally new errors may be introduced. There is a paucity of studies assessing the use and impact of EP in the UK hospital setting, especially those involving paediatric patients. The aim of this thesis was to investigate and evaluate the implementation of an EP system at a children's hospital in the UK. The objectives were to assess the effect on prescribing errors, to explore the level of CDSS available and in use within the system, to identify any changes in practice and workflow patterns of healthcare professionals, and to determine the views of patients and users. Mixed qualitative and quantitative methods were used within an evaluation framework (the Cornford framework). The results show an overall reduction in prescribing errors directly as a result of more complete and legible prescriptions after EP. Outpatient errors decreased from 1219/1574 (77.4%) to 33/648 (5.1%), a 72.3% reduction [95% confidence interval (CI) -74.6% to -69.3%]. The number of outpatient visits that were error free increased from 185/883 (21%) to 225/250 (90%), 95% Cl of difference in proportions, 64% to 73.4%. Inpatient errors decreased from 85/1267 (6.7%) to 96/ 2079 (4.6%), 95% CI of difference in proportions, -3.4% to -0.5% There was an increase in discharge prescription errors from 839/1098 (76.4%>) to 1777/2057 (86.4%), 95% CI of difference in proportions, 7.88% to 12.94%. The dosing error rate in all types of prescriptions was lower after EP: 88/3939 (2.2%) vs. 57/4784 (1.2%), 95% CI of difference in proportions, -1.6% to -0.5%, but there was no statistically significant change in severity ratings of dosing errors. New types of errors, such as selection errors, were seen due to EP. Although principles of the medicines use process remained the same, the practical approach to tasks was altered. The system was accepted by users and patients, but there was a desire for further improvements, especially in the level of clinical decision support available to the end user. In conclusion, the EP system was implemented successfully. The benefits in medication safety appear to be the results of effective interaction between system functionality and usability, user acceptance and organisational infrastructure

Can the Heinrich ratio be used to predict harm from medication errors?

The purpose of this study was to establish whether, for medication errors, there exists a fixed Heinrich ratio between the number of incidents which did not result in harm, the number that caused minor harm, and the number that caused serious harm. If this were the case then it would be very useful in estimating any changes in harm following an intervention. Serious harm resulting from medication errors is relatively rare, so it can take a great deal of time and resource to detect a significant change. If the Heinrich ratio exists for medication errors, then it would be possible, and far easier, to measure the much more frequent number of incidents that did not result in harm and the extent to which they changed following an intervention; any reduction in harm could be extrapolated from this

A framework for development of android mobile electronic prescription transfer applications in compliance with security requirements mandated by the Australian healthcare industry

This thesis investigates mobile electronic transfer of prescription (ETP) in compliance with the security requirements mandated by the Australian healthcare industry and proposes a framework for the development of an Android mobile electronic prescription transfer application. Furthermore, and based upon the findings and knowledge from constructing this framework, another framework is also derived for assessing Android mobile ETP applications for their security compliance. The centralised exchange model-based ETP solution currently used in the Australian healthcare industry is an expensive solution for on-going use. With challenges such as an aging population and the rising burden of chronic disease, the cost of the current ETP solution’s operational infrastructure is certain to rise in the future. In an environment where it is increasingly beneficial for patients to engage in and manage their own information and subsequent care, this current solution fails to offer the patient direct access to their electronic prescription information. The current system also fails to incorporate certain features that would dramatically improve the quality of the patient’s care and safety, i.e. alerts for the patient’s drug allergies, harmful dosage and script expiration. Over a decade old, the current ETP solution was essentially designed and built to meet legislation and regulatory requirements, with change-averting its highest priority. With little, if any, provision for future growth and innovation, it was not designed to cater to the needs of the ETP process. This research identifies the gap within the current ETP implementation (i.e. dependency on infrastructure, significant on-going cost and limited availability of the patient’s medication history) and proposes a framework for building a secure mobile ETP solution on the Android mobile operating system platform which will address the identified gap. The literature review part of this thesis examined the significance of ETP for the nation’s larger initiative to provide an improved and better maintainable healthcare system. The literature review also revealed the stance of each jurisdiction, from legislative and regulatory perspectives, in transitioning to the use of a fully electronic ETP solution. It identified the regulatory mandates of each jurisdiction for ETP as well as the security standards by which the current ETP implementation is iii governed so as to conform to those regulatory mandates. The literature review part of the thesis essentially identified and established how the Australian healthcare industry’s various prescription-related legislations and regulations are constructed, and the complexity of this construction for eTP. The jurisdictional regulatory mandates identified in the literature review translate into a set of security requirements. These requirements establish the basis of the guiding framework for the development of a security-compliant Android mobile ETP application. A number of experimentations were conducted focusing on the native security features of the Android operating system, as well as wireless communication technologies such as NFC and Bluetooth, in order to propose an alternative mobile ETP solution with security assurance comparable to the current ETP implementation. The employment of a proof-of-concept prototype such as this alongside / coupled with a series of iterative experimentations strengthens the validity and practicality of the proposed framework. The first experiment successfully proved that the Android operating system has sufficient encryption capabilities, in compliance with the security mandates, to secure the electronic prescription information from the data at rest perspective. The second experiment indicated that the use of NFC technology to implement the alternative transfer mechanism for exchanging electronic prescription information between ETP participating devices is not practical. The next iteration of the experimentation using Bluetooth technology proved that it can be utilised as an alternative electronic prescription transfer mechanism to the current approach using the Internet. These experiment outcomes concluded the partial but sufficient proofof- concept prototype for this research. Extensive document analysis and iterative experimentations showed that the framework constructed by this research can guide the development of an alternative mobile ETP solution with both comparable security assurance to and better access to the patient’s medication history than the current solution. This alternative solution would present no operational dependence upon infrastructure and its associated, ongoing cost to the nation’s healthcare expenditure. In addition, use of this mobile ETP alternative has the potential to change the public’s perception (i.e. acceptance from regulatory and security perspectives) of mobile healthcare solutions, thereby paving the way for further innovation and future enhancements in eHealth

Risk assessment of patients as a means of directing a clinical pharmacy service

The aim of this research was to develop a new work model for hospital pharmacists based on risk assessment of patients using an electronic prescribing and administration system (EPMA). Systematic review was performed to identify risk factors associated with clinical pharmacy intervention. Those factors which can be measured by the EPMA in a UK teaching hospital were subsequently identified. Data was extracted from the EPMA relating to risks in intervention recipients on medical and surgical wards and those patients present concurrently. Univariable and multivariable analysis was performed and a risk score calculated. Receiver operating curves (ROCs) determined predictability of the score. Risk factors for pharmacist intervention were: age, female gender, patient compliance, unavailable stock, prescription of warfarin, number of allergies, comorbidities, regular prescriptions, anti-epileptics, thrombolytics/anticoagulants, central nervous system agents, and chemotherapy / immunosuppressants. The area under the ROC for the risk score was 0.61. Multiple factors were significantly and independently associated, with an increased intervention rate. However, it was not possible to generate a useful model for directing clinical pharmacy services. Inverse relationships were demonstrated between some risk factors usually associated with problems with medicines use