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1.
Tosha B Wetterneck James M Walker Mary Ann Blosky Randi S Cartmill Peter Hoonakker Mark A Johnson Evan Norfolk Pascale Carayon 《J Am Med Inform Assoc》2011,18(6):774-782
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. 相似文献2.
Brian L Strom Rita Schinnar Warren Bilker Sean Hennessy Charles E Leonard Eric Pifer 《J Am Med Inform Assoc》2010,17(4):411-415
Background
Studies that have looked at the effectiveness of computerized decision support systems to prevent drug–drug interactions have reported modest results because of low response by the providers to the automated alerts.Objective
To evaluate, within an inpatient computerized physician order entry (CPOE) system, the incremental effectiveness of an alert that required a response from the provider, intended as a stronger intervention to prevent concurrent orders of warfarin and non-steroidal anti-inflammatory drugs (NSAIDs).Design
Randomized clinical trial of 1963 clinicians assigned to either an intervention group receiving a customized electronic alert requiring affirmative response or a control group receiving a commercially available passive alert as part of the CPOE. The study duration was 2 August 2006 to 15 December 2007.Measurements
Alert adherence was compared between study groups.Results
The proportion of desired ordering responses (ie, not reordering the alert-triggering drug after firing) was lower in the intervention group (114/464 (25%) customized alerts issued) than in the control group (154/560 (28%) passive alerts firing). The adjusted OR of inappropriate ordering was 1.22 (95% CI 0.69 to 2.16).Conclusion
A customized CPOE alert that required a provider response had no effect in reducing concomitant prescribing of NSAIDs and warfarin beyond that of the commercially available passive alert received by the control group. New CPOE alerts cannot be assumed to be effective in improving prescribing, and need evaluation. 相似文献3.
Andrew Georgiou Mirela Prgomet Andrew Markewycz Edwina Adams Johanna I Westbrook 《J Am Med Inform Assoc》2011,18(3):335-340
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. 相似文献4.
5.
Eppenga WL Derijks HJ Conemans JM Hermens WA Wensing M De Smet PA 《J Am Med Inform Assoc》2012,19(1):66-71
Objective
To compare the clinical relevance of medication alerts in a basic and in an advanced clinical decision support system (CDSS).Design
A prospective observational study.Materials and methods
We collected 4023 medication orders in a hospital for independent evaluation in two pharmacotherapy-related decision support systems. Only the more advanced system considered patient characteristics and laboratory test results in its algorithms. Two pharmacists assessed the clinical relevance of the medication alerts produced. The alert was considered relevant if the pharmacist would undertake action (eg, contact the physician or the nurse). The primary analysis concerned the positive predictive value (PPV) for clinically relevant medication alerts in both systems.Results
The PPV was significantly higher in the advanced system (5.8% vs 17.0%; p<0.05). Significant differences were found in the alert categories: drug–(drug) interaction (9.9% vs 14.8%; p<0.05), drug–age interaction (2.9% vs 73.3%; p<0.05), and dosing guidance (5.6% vs 16.9%; p<0.05). Including laboratory values and other patient characteristics resulted in a significantly higher PPV for the advanced CDSS compared to the basic medication alerts (12.2% vs 23.3%; p<0.05).Conclusion
The advanced CDSS produced a higher proportion of clinically relevant medication alerts, but the number of irrelevant alerts remained high. To improve the PPV of the advanced CDSS, the algorithms should be optimized by identifying additional risk modifiers and more data should be made electronically available to improve the performance of the algorithms. Our study illustrates and corroborates the need for cyclic testing of technical improvements in information technology in circumstances representative of daily clinical practice. 相似文献6.
Yu Ko Jacob Abarca Daniel C. Malone Donna C. Dare Doug Geraets Antoun Houranieh William N. Jones W. Paul Nichol Gregory P. Schepers Michelle Wilhardt 《J Am Med Inform Assoc》2007,14(1):56-64
Objectives
To assess Veterans Affairs (VA) prescribers’ and pharmacists’ opinions about computer-generated drug–drug interaction (DDI) alerts and obtain suggestions for improving DDI alerts.Design
A mail survey of 725 prescribers and 142 pharmacists from seven VA medical centers across the United States.Measurements
A questionnaire asked respondents about their sources of drug and DDI information, satisfaction with the combined inpatient and outpatient computerized prescriber order entry (CPOE) system, attitude toward DDI alerts, and suggestions for improving DDI alerts.Results
The overall response rate was 40% (prescribers: 36%; pharmacists: 59%). Both prescribers and pharmacists indicated that the CPOE system had a neutral to positive impact on their jobs. DDI alerts were not viewed as a waste of time and the majority (61%) of prescribers felt that DDI alerts had increased their potential to prescribe safely. However, only 30% of prescribers felt DDI alerts provided them with what they needed most of the time. Both prescribers and pharmacists agreed that DDI alerts should be accompanied by management alternatives (73% and 82%, respectively) and more detailed information (65% and 89%, respectively). When asked about suggestions for improving DDI alerts, prescribers most preferred including management options whereas pharmacists most preferred making it more difficult to override lethal interactions. Prescribers and pharmacists reported primarily relying on electronic references for general drug information (62% and 55%, respectively) and DDI information (51% and 79%, respectively).Conclusion
Respondents reported neutral to positive views regarding the effect of CPOE on their jobs. Their opinions suggest DDI alerts are useful but still require additional work to increase their clinical utility. 相似文献7.
Gregory P T Scott Priya Shah Jeremy C Wyatt Boikanyo Makubate Frank W Cross 《J Am Med Inform Assoc》2011,18(6):789-798
Objective
Expert authorities recommend clinical decision support systems to reduce prescribing error rates, yet large numbers of insignificant on-screen alerts presented in modal dialog boxes persistently interrupt clinicians, limiting the effectiveness of these systems. This study compared the impact of modal and non-modal electronic (e-) prescribing alerts on prescribing error rates, to help inform the design of clinical decision support systems.Design
A randomized study of 24 junior doctors each performing 30 simulated prescribing tasks in random order with a prototype e-prescribing system. Using a within-participant design, doctors were randomized to be shown one of three types of e-prescribing alert (modal, non-modal, no alert) during each prescribing task.Measurements
The main outcome measure was prescribing error rate. Structured interviews were performed to elicit participants'' preferences for the prescribing alerts and their views on clinical decision support systems.Results
Participants exposed to modal alerts were 11.6 times less likely to make a prescribing error than those not shown an alert (OR 11.56, 95% CI 6.00 to 22.26). Those shown a non-modal alert were 3.2 times less likely to make a prescribing error (OR 3.18, 95% CI 1.91 to 5.30) than those not shown an alert. The error rate with non-modal alerts was 3.6 times higher than with modal alerts (95% CI 1.88 to 7.04).Conclusions
Both kinds of e-prescribing alerts significantly reduced prescribing error rates, but modal alerts were over three times more effective than non-modal alerts. This study provides new evidence about the relative effects of modal and non-modal alerts on prescribing outcomes. 相似文献8.
9.
Sylvia J Hysong Mona K Sawhney Lindsay Wilson Dean F Sittig Donna Espadas Traber Davis Hardeep Singh 《J Am Med Inform Assoc》2010,17(1):71-77
Objective
Electronic medical records (EMRs) facilitate abnormal test result communication through “alert” notifications. The aim was to evaluate how primary care providers (PCPs) manage alerts related to critical diagnostic test results on their EMR screens, and compare alert-management strategies of providers with high versus low rates of timely follow-up of results.Design
28 PCPs from a large, tertiary care Veterans Affairs Medical Center (VAMC) were purposively sampled according to their rates of timely follow-up of alerts, determined in a previous study. Using techniques from cognitive task analysis, participants were interviewed about how and when they manage alerts, focusing on four alert-management features to filter, sort and reduce unnecessary alerts on their EMR screens.Results
Provider knowledge of alert-management features ranged between 4% and 75%. Almost half (46%) of providers did not use any of these features, and none used more than two. Providers with higher versus lower rates of timely follow-up used the four features similarly, except one (customizing alert notifications). Providers with low rates of timely follow-up tended to manually scan the alert list and process alerts heuristically using their clinical judgment. Additionally, 46% of providers used at least one workaround strategy to manage alerts.Conclusion
Considerable heterogeneity exists in provider use of alert-management strategies; specific strategies may be associated with lower rates of timely follow-up. Standardization of alert-management strategies including improving provider knowledge of appropriate tools in the EMR to manage alerts could reduce the lack of timely follow-up of abnormal diagnostic test results. 相似文献10.
11.
Tamblyn R Eguale T Buckeridge DL Huang A Hanley J Reidel K Shi S Winslade N 《J Am Med Inform Assoc》2012,19(4):635-643
Context
Computerized drug alerts for psychotropic drugs are expected to reduce fall-related injuries in older adults. However, physicians over-ride most alerts because they believe the benefit of the drugs exceeds the risk.Objective
To determine whether computerized prescribing decision support with patient-specific risk estimates would increase physician response to psychotropic drug alerts and reduce injury risk in older people.Design
Cluster randomized controlled trial of 81 family physicians and 5628 of their patients aged 65 and older who were prescribed psychotropic medication.Intervention
Intervention physicians received information about patient-specific risk of injury computed at the time of each visit using statistical models of non-modifiable risk factors and psychotropic drug doses. Risk thermometers presented changes in absolute and relative risk with each change in drug treatment. Control physicians received commercial drug alerts.Main outcome measures
Injury risk at the end of follow-up based on psychotropic drug doses and non-modifiable risk factors. Electronic health records and provincial insurance administrative data were used to measure outcomes.Results
Mean patient age was 75.2 years. Baseline risk of injury was 3.94 per 100 patients per year. Intermediate-acting benzodiazepines (56.2%) were the most common psychotropic drug. Intervention physicians reviewed therapy in 83.3% of visits and modified therapy in 24.6%. The intervention reduced the risk of injury by 1.7 injuries per 1000 patients (95% CI 0.2/1000 to 3.2/1000; p=0.02). The effect of the intervention was greater for patients with higher baseline risks of injury (p<0.03).Conclusion
Patient-specific risk estimates provide an effective method of reducing the risk of injury for high-risk older people.Trial registration number
clinicaltrials.gov Identifier: NCT00818285. 相似文献12.
Svetla Gadzhanova Ivan I. Iankov James R. Warren Jan Stanek Gary M. Misan Zak Baig Lorenzo Ponte 《J Am Med Inform Assoc》2007,14(1):100-109
Objective
This paper presents a model for analysis of chronic disease prescribing action over time in terms of transitions in status of therapy as indicated in electronic prescribing records. The quality of alerts derived from these therapeutic state transitions is assessed in the context of antihypertensive prescribing.Design
A set of alert criteria is developed based on analysis of state-transition in past antihypertensive prescribing of a rural Australian General Practice. Thirty active patients coded as hypertensive with alerts on six months of previously un-reviewed prescribing, and 30 hypertensive patients without alerts, are randomly sampled and independently reviewed by the practice’s two main general practice physicians (GPs), each GP reviewing 20 alert and 20 non-alert cases (providing 10 alert and 10 non-alert cases for agreement assessment).Measurements
GPs provide blind assessment of quality of hypertension management and retrospective assessment of alert relevance.Results
Alerts were found on 66 of 611 cases with coded hypertension with 37 alerts on the 30 sampled alert cases. GPs assessed alerting sensitivity as 74% (CI 52% - 89%) and specificity as 61% (CI 45% - 74%) for the sample, which is estimated as 26% sensitivity and 93% specificity for the antihypertensive population. Agreement between the GPs on assessment of alert relevance was fair (kappa = 0.37).Conclusions
Data-driven development of alerts from electronic prescribing records using analysis of therapeutic state transition shows promise for derivation of high-specificity alerts to improve the quality of chronic disease management activities. 相似文献13.
Objective
To assess evidence of the impact of Picture Archiving and Communication Systems (PACS) on clinicians'' work practices in the intensive care unit (ICU).Methods
We searched Medline, Pre-Medline, CINAHL, Embase, and the SPIE Digital Library databases for English-language publications between 1980 and September 2010 using Medical Subject Headings terms and keywords.Results
Eleven studies from the USA and UK were included. All studies measured aspects of time associated with the introduction of PACS, namely the availability of images, the time a physician took to review an image, and changes in viewing patterns. Seven studies examined the impact on clinical decision-making, with the majority measuring the time to image-based clinical action. The effect of PACS on communication modes was reported in five studies.Discussion
PACS can impact on clinician work practices in three main areas. Most of the evidence suggests an improvement in the efficiency of work practices. Quick image availability can impact on work associated with clinical decision-making, although the results were inconsistent. PACS can change communication practices, particularly between the ICU and radiology; however, the evidence base is insufficient to draw firm conclusions in this area.Conclusion
The potential for PACS to impact positively on clinician work practices in the ICU and improve patient care is great. However, the evidence base is limited and does not reflect aspects of contemporary PACS technology. Performance measures developed in previous studies remain relevant, with much left to investigate to understand how PACS can support new and improved ways of delivering care in the intensive care setting. 相似文献14.
Heleen van der Sijs Jos Aarts Teun van Gelder Marc Berg Arnold Vulto 《J Am Med Inform Assoc》2008,15(4):439-448
Objectives
This study sought to identify opportunities to safely turn off frequently overridden drug–drug interaction alerts (DDIs) in computerized physician order entry (CPOE).Design
Quantitative retrospective analysis of drug safety alerts overridden during 1 month and qualitative interviews with 24 respondents (18 physicians and 6 pharmacists) about turning off frequently overridden DDI alerts, based on the Dutch drug database, in a hospital setting. Screen shots and complete texts of frequently overridden DDIs were presented to physicians of internal medicine, cardiology, and surgery and to hospital pharmacists who were asked whether these could be turned off hospital-wide without impairing patient safety, and the reasons for their recommendations.Results
Data on the frequency of alerts overridden in 1 month identified 3,089 overrides, of which 1,963 were DDIs. The category DDIs showed 86 different alerts, of which 24 frequently overridden alerts, accounting for 72% of all DDI overrides, were selected for further evaluation. The 24 respondents together made 576 assessments. Upon investigation, differences in the reasons for turning off alerts were found across medical specialties and among respondents within a specialty. Frequently mentioned reasons for turning off were “alert well known,” “alert not serious,” or “alert not needing (additional) action,” or that the effects of the combination were monitored or intended. For none of the alerts did all respondents agree that it could be safely turned off hospital-wide. The highest agreement was 13 of 24 respondents (54%). A positive correlation was found between the number of alerts overridden and the number of clinicians recommending to turn them off.Conclusion
Although the Dutch drug database is already a selected reduction from all DDIs mentioned in literature, the majority of respondents wanted to turn off DDI alerts to reduce alert overload. Turning off DDI alerts hospital-wide appeared to be problematic because of differences among physicians regarding drug-related knowledge and of differences across the hospital in routine drug monitoring practices. Furthermore, several reasons for suppression of alerts could be questioned from a safety perspective. Further research should investigate when each of the following might help: changes in alert texts; new differential alert triggers based on clinician knowledge or specialty; and nonintrusive alert presentation so long as serum levels and patient parameters are measured and stay within limits. 相似文献15.
16.
Pascale Carayon Randi Cartmill Mary Ann Blosky Roger Brown Matthew Hackenberg Peter Hoonakker Ann Schoofs Hundt Evan Norfolk Tosha B Wetterneck James M Walker 《J Am Med Inform Assoc》2011,18(6):812-819
Objective
To assess intensive care unit (ICU) nurses'' acceptance of electronic health records (EHR) technology and examine the relationship between EHR design, implementation factors, and nurse acceptance.Design
The authors analyzed data from two cross-sectional survey questionnaires distributed to nurses working in four ICUs at a northeastern US regional medical center, 3 months and 12 months after EHR implementation.Measurements
Survey items were drawn from established instruments used to measure EHR acceptance and usability, and the usefulness of three EHR functionalities, specifically computerized provider order entry (CPOE), the electronic medication administration record (eMAR), and a nursing documentation flowsheet.Results
On average, ICU nurses were more accepting of the EHR at 12 months as compared to 3 months. They also perceived the EHR as being more usable and both CPOE and eMAR as being more useful. Multivariate hierarchical modeling indicated that EHR usability and CPOE usefulness predicted EHR acceptance at both 3 and 12 months. At 3 months postimplementation, eMAR usefulness predicted EHR acceptance, but its effect disappeared at 12 months. Nursing flowsheet usefulness predicted EHR acceptance but only at 12 months.Conclusion
As the push toward implementation of EHR technology continues, more hospitals will face issues related to acceptance of EHR technology by staff caring for critically ill patients. This research suggests that factors related to technology design have strong effects on acceptance, even 1 year following the EHR implementation. 相似文献17.
Melissa T Baysari Johanna I Westbrook Katrina L Richardson Richard O Day 《J Am Med Inform Assoc》2011,18(6):754-759
Objective
To assess whether a low level of decision support within a hospital computerized provider order entry system has an observable influence on the medication ordering process on ward-rounds and to assess prescribers'' views of the decision support features.Methods
14 specialty teams (46 doctors) were shadowed by the investigator while on their ward-rounds and 16 prescribers from these teams were interviewed.Results
Senior doctors were highly influential in prescribing decisions during ward-rounds but rarely used the computerized provider order entry system. Junior doctors entered the majority of medication orders into the system, nearly always ignored computerized alerts and never raised their occurrence with other doctors on ward-rounds. Interviews with doctors revealed that some decision support features were valued but most were not perceived to be useful.Discussion and conclusion
The computerized alerts failed to target the doctors who were making the prescribing decisions on ward-rounds. Senior doctors were the decision makers, yet the junior doctors who used the system received the alerts. As a result, the alert information was generally ignored and not incorporated into the decision-making processes on ward-rounds. The greatest value of decision support in this setting may be in non-ward-round situations where senior doctors are less influential. Identifying how prescribing systems are used during different clinical activities can guide the design of decision support that effectively supports users in different situations. If confirmed, the findings reported here present a specific focus and user group for designers of medication decision support. 相似文献18.
Julie Chan Kaveh G Shojania Anthony C Easty Edward E Etchells 《J Am Med Inform Assoc》2011,18(3):276-281
Background
Application of user-centred design principles to Computerized provider order entry (CPOE) systems may improve task efficiency, usability or safety, but there is limited evaluative research of its impact on CPOE systems.Objective
We evaluated the task efficiency, usability, and safety of three order set formats: our hospital''s planned CPOE order sets (CPOE Test), computer order sets based on user-centred design principles (User Centred Design), and existing pre-printed paper order sets (Paper).Participants
27staff physicians, residents and medical students.Setting
Sunnybrook Health Sciences Centre, an academic hospital in Toronto, Canada.Methods
Participants completed four simulated order set tasks with three order set formats (two CPOE Test tasks, one User Centred Design, and one Paper). Order of presentation of order set formats and tasks was randomized. Users received individual training for the CPOE Test format only.Main Measures
Completion time (efficiency), requests for assistance (usability), and errors in the submitted orders (safety).Results
27 study participants completed 108 order sets. Mean task times were: User Centred Design format 273 s, Paper format 293 s (p=0.73 compared to UCD format), and CPOE Test format 637 s (p<0.0001 compared to UCD format). Users requested assistance in 31% of the CPOE Test format tasks, whereas no assistance was needed for the other formats (p<0.01). There were no significant differences in number of errors between formats.Conclusions
The User Centred Design format was more efficient and usable than the CPOE Test format even though training was provided for the latter. We conclude that application of user-centred design principles can enhance task efficiency and usability, increasing the likelihood of successful implementation. 相似文献19.
Fern FitzHenry Josh F. Peterson Mark Arrieta Lemuel R. Waitman Jonathan S. Schildcrout Randolph A. Miller 《J Am Med Inform Assoc》2007,14(6):756-764
Background
Up to 38% of inpatient medication errors occur at the administration stage. Although they reduce prescribing errors, computerized provider order entry (CPOE) systems do not prevent administration errors or timing discrepancies. This study determined the degree to which CPOE medication orders matched actual dose administration times.Methods
At a 658-bed academic hospital with CPOE but lacking electronic medication administration charting, authors randomly selected adult patients with eligible medication orders from historical 1999–2003 CPOE log files. Retrospective manual chart audits compared expected (from CPOE) and actual timing of medication administrations. Outcomes included: dose omissions, median lag times between ordered and charted administrations, unauthorized doses, wrong dose errors, and the rate of nurses’ medication schedule shifting.Results
Dose omissions occurred in 756 of 6019 (12.6%) audited administration opportunities; only 313 of the omissions (5.2% of opportunities) were unexplained. Wrong doses and unexpected doses occurred for 0.1% and 0.7% of opportunities, respectively. Median lag from expected first dose to actual charted administration time was 27 minutes (IQR 0-127). Nursing staff shifted from ordered to alternate administration schedules for 10.7% of regularly scheduled recurring medication orders. Chart review identified reasons for dose omissions, delays, and dose shifting.Conclusion
Inpatient CPOE orders are legible and conveyed electronically to nurses and the pharmacy. Nonetheless, ward-based medication administrations do not consistently occur as ordered. Medication administration discrepancies are likely to persist even after implementing CPOE and bar-coded medication administration unless recommended interventions are made to address issues such as determining the true urgency of medication administration, avoiding overlapping duplicative medication orders, and developing a safe means for shifting dosing schedules. 相似文献20.