Characteristics and consequences of drug allergy alert overrides in a computerized physician order entry system

ObjectiveThe aim of this study was to determine characteristics of drug allergy alert overrides, assess how often they lead to preventable adverse drug events (ADEs), and suggest methods for improving the allergy-alerting system.DesignChart review was performed on a stratified random subset of all allergy alerts occurring during a 3-month period (August through October 2002) at a large academic hospital.MeasurementsFactors that were measured were drug/allergy combinations that triggered alerts, frequency of specific override reasons, characteristics of ADEs, and completeness of allergy documentation.ResultsA total of 6,182 (80%) of 7,761 alerts were overridden in 1,150 patients. In this sample, only 10% of alerts were triggered by an exact match between the drug ordered and allergy listed. Physicians' most common reasons for overriding alerts were “Aware/Will monitor” (55%), “Patient does not have this allergy/tolerates” (33%), and “Patient taking already” (10%). In a stratified random subset of 320 patients (28% of 1,150) on chart review, 19 (6%) experienced ADEs attributed to the overridden drug; of these, 9 (47%) were serious. None of the ADEs was considered preventable, because the overrides were deemed clinically justifiable. The degree of completeness of patients' allergy lists was highly variable and generally low in both paper charts and the CPOE system.ConclusionOverrides of drug-allergy alerts were common and about 1 in 20 resulted in ADEs, but all of the overrides resulting in ADEs appeared clinically justifiable. The high rate of alert overrides was attributable to frequent nonexact match alerts and infrequent updating of allergy lists. Based on these findings, we have made specific recommendations for increasing the specificity of alerting and thereby improving the clinical utility of the drug allergy alerting system.     

临床电子医嘱CPOE对医疗质量的影响与投资效益研究

患者药物不良反心（ADEs）对医院医疗质量有重要影响,绝大部分ADEs事件都能通过信息系统进行预防,由于资金投入以及一作流氍的改变,临床电子陕嘱（CPOE）应用遇到了许多困难。上海交通大学附属第六人民医院通过将CPOE与临床决策支持结合,显著降低了医疗差错．通过减少不必要的临床环节节省了大景医疗成本,并且约26个月就可以完全收回系统的投资成本。CPOE应用为医院电了病历应用水平提升提供了重要契机,也为循证医疗提供了重要的信息化发展基础。     

The impact of computerized provider order entry systems on medical-imaging services: a systematic review

Background

Computerized provider order entry (CPOE) systems have been strongly promoted as a means to improve the quality and efficiency of healthcare.

Methods

This systematic review aimed to assess the evidence of the impact of CPOE on medical-imaging services and patient outcomes.

Results

Fourteen studies met the inclusion criteria, most of which (10/14) used a pre-/postintervention comparison design. Eight studies demonstrated benefits, such as decreased test utilization, associated with decision-support systems promoting adherence to test ordering guidelines. Three studies evaluating medical-imaging ordering and reporting times showed statistically significant decreases in turnaround times.

Conclusions

The findings reveal the potential for CPOE to contribute to significant efficiency and effectiveness gains in imaging services. The diversity and scope of the research evidence can be strengthened through increased attention to the circumstances and mechanisms that contribute to the success (or otherwise) of CPOE and its contribution to the enhancement of patient care delivery.     

A study of renal function influence by integrating cloud-based manometers and physician order entry systems

BackgroundNo evidence exists from randomized trials to support using cloud-based manometers integrated with available physician order entry systems for tracking patient blood pressure (BP) to assist in the control of renal function deterioration. We investigated how integrating cloud-based manometers with physician order entry systems benefits our outpatient chronic kidney disease patients compared with typical BP tracking systems.MethodsWe randomly assigned 36 chronic kidney disease patients to use cloud-based manometers integrated with physician order entry systems or typical BP recording sheets, and followed the patients for 6 months. The composite outcome was that the patients saw improvement both in BP and renal function.ResultsWe compared the systolic and diastolic BP (SBP and DBP), and renal function of our patients at 0 months, 3 months, and 6 months after using the integrated manometers and typical BP monitoring sheets. Nighttime SBP and DBP were significantly lower in the study group compared with the control group. Serum creatinine level in the study group improved significantly compared with the control group after the end of Month 6 (2.83 ± 2.0 vs. 4.38 ± 3.0, p = 0.018). Proteinuria improved nonsignificantly in Month 6 in the study group compared with the control group (1.05 ± 0.9 vs. 1.90 ± 1.3, p = 0.09). Both SBP and DBP during the nighttime hours improved significantly in the study group compared with the baseline.ConclusionIn pre–end-stage renal disease patients, regularly monitoring BP by integrating cloud-based manometers appears to result in a significant decrease in creatinine and improvement in nighttime BP control. Estimated glomerular filtration rate and proteinuria were found to be improved nonsignificantly, and thus, larger population and longer follow-up studies may be needed.     

Factors contributing to an increase in duplicate medication order errors after CPOE implementation

Objective

To evaluate the incidence of duplicate medication orders before and after computerized provider order entry (CPOE) with clinical decision support (CDS) implementation and identify contributing factors.

Design

CPOE with duplicate medication order alerts was implemented in a 400-bed Northeastern US community tertiary care teaching hospital. In a pre-implementation post-implementation design, trained nurses used chart review, computer-generated reports of medication orders, provider alerts, and staff reports to identify medication errors in two intensive care units (ICUs).

Measurement

Medication error data were adjudicated by a physician and a human factors engineer for error stage and type. A qualitative analysis of duplicate medication ordering errors was performed to identify contributing factors.

Results

Data were collected for 4147 patient-days pre-implementation and 4013 patient-days post-implementation. Duplicate medication ordering errors increased after CPOE implementation (pre: 48 errors, 2.6% total; post: 167 errors, 8.1% total; p<0.0001). Most post-implementation duplicate orders were either for the identical order or the same medication. Contributing factors included: (1) provider ordering practices and computer availability, for example, two orders placed within minutes by different providers on rounds; (2) communication and hand-offs, for example, duplicate orders around shift change; (3) CDS and medication database design, for example confusing alert content, high false-positive alert rate, and CDS algorithms missing true duplicates; (4) CPOE data display, for example, difficulty reviewing existing orders; and (5) local CDS design, for example, medications in order sets defaulted as ordered.

Conclusions

Duplicate medication order errors increased with CPOE and CDS implementation. Many work system factors, including the CPOE, CDS, and medication database design, contributed to their occurrence.     

Assessing the quality of data entry in a computerized medical records system

A primary care university clinic discovered major errors in its medical records after instituting a computerized medical records system. A quality assessment tool was devised to measure the error rate and provide clues to the sources of these errors. During the implementation of this tool a marked reduction in data entry errors occurred suggesting its use had a positive impact on our medical record quality.     

Profiling harmful medication errors in an acute Irish teaching hospital

Background

Medication error reporting systems in hospitals are faced with the challenge of processing vast numbers of reports which identify a myriad of safety issues. With such large volumes of data and limited resources it makes sense to adopt a prioritisation approach. Several published studies have focused solely on the subset of errors which cause patient harm. The majority of such research has concerned the individual analysis of criteria associated with medication errors. However, the research described here used an alternative approach which involved linking the three criteria of medication class, patient outcome, and type of error, in order to describe the medication-related scenarios presenting greatest risk to the organisation.

Aims

To identify the highest-priority medication-related risks in an acute teaching hospital. To profile harmful medication errors submitted to a voluntary reporting system in a tertiary healthcare setting in Ireland.

Methods

A database of medication errors, reported via an internal voluntary reporting system over a 5-year period, was analysed. The criteria of medication class, patient outcome and type of error were analysed separately and then cross-tabulated.

Results

The medication classes, error types and adverse patient outcomes most frequently associated with harm were identified. The cross-tabulation highlighted ten priority risk areas which accounted for the majority of patient harm.

Conclusions

A cross-tabulation strategy for prioritising medication-associated risks was successfully applied to a hospital database comprising medication errors. The profile developed for harmful medication errors in this acute tertiary healthcare setting was broadly in line with that published for error reporting systems internationally.     

Clinical usefulness of computerized ECG systems

Computer ECG systems provide a valuable function for ECG analysis, storage, retrieval, and serial comparison. The current systems can provide quality control of technician performance, acquisition equipment, and physician overreading. Its overall acceptability and clinical usefulness is documented in a clinical practice setting with a 90.4% computer-physician agreement in more than 20,000 ECGs. Computerized ECG systems have demonstrated their clinical usefulness in patient care.