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

Clinical decision support alert appropriateness: A review and proposal for improvement

Background: Many healthcare providers are adopting clinical decision support (CDS) systems to improve patient safety and meet meaningful use requirements. Computerized alerts that prompt clinicians about drug-allergy, drug-drug, and drugdisease warnings or provide dosing guidance are most commonly implemented. Alert overrides, which occur when clinicians do not follow the guidance presented by the alert, can hinder improved patient outcomes. Methods: We present a review of CDS alerts and describe a proposal to develop novel methods for evaluating and improving CDS alerts that builds upon traditional informatics approaches. Our proposal incorporates previously described models for predicting alert overrides that utilize retrospective chart review to determine which alerts are clinically relevant and which overrides are justifiable. Results: Despite increasing implementations of CDS alerts, detailed evaluations rarely occur because of the extensive labor involved in manual chart reviews to determine alert and response appropriateness. Further, most studies have solely evaluated alert overrides that are appropriate or justifiable. Our proposal expands the use of web-based monitoring tools with an interactive dashboard for evaluating CDS alert and response appropriateness that incorporates the predictive models. The dashboard provides 2 views, an alert detail view and a patient detail view, to provide a full history of alerts and help put the patient's events in context. Conclusion: The proposed research introduces several innovations to address the challenges and gaps in alert evaluations. This research can transform alert evaluation processes across healthcare settings, leading to improved CDS, reduced alert fatigue, and increased patient safety

Methodological integrative review of the work sampling technique used in nursing workload research

Aim. To critically review the work sampling technique used in nursing workload research. Background. Work sampling is a technique frequently used by researchers and managers to explore and measure nursing activities. However, work sampling methods used are diverse making comparisons of results between studies difficult. Design. Methodological integrative review. Data Sources. Four electronic databases were systematically searched for peer-reviewed articles published between 2002–2012. Manual scanning of reference lists and Rich Site Summary feeds from contemporary nursing journals were other sources of data. Review Methods. Articles published in the English language between 2002– 2012 reporting on research which used work sampling to examine nursing workload. Results. Eighteen articles were reviewed. The review identified that the work sampling technique lacks a standardized approach, which may have an impact on the sharing or comparison of results. Specific areas needing a shared understanding included the training of observers and subjects who self-report, standardization of the techniques used to assess observer inter-rater reliability, sampling methods and reporting of outcomes. Conclusion. Work sampling is a technique that can be used to explore the many facets of nursing work. Standardized reporting measures would enable greater comparison between studies and contribute to knowledge more effectively. Author suggestions for the reporting of results may act as guidelines for researchers considering work sampling as a research method