Hindmarsh J, Holden K. Int J Med Inform. 2022;163:104777.
Computerized provider order entry has become standard practice for most medication ordering. This article reports on the safety and efficiency of ordering mixed-drug infusions before and after implementation of electronic prescribing. After implementation, rates of prescription errors, time to process discharge orders, and time between prescription and administration all decreased.
Colombini N, Abbes M, Cherpin A, et al. Int J Med Inform. 2022;160:104703.
Computerized provider order entry (CPOE) refers to a system in which clinicians directly place orders electronically to be sent to the receiver (e.g., pharmacist). This French hospital analyzed hospital discharge orders (HDO) over a six-month period to evaluate the use rate of CPOE, prescription concordance between CPOE-edited HDO, exit prescriptions transcribed in the discharge summary, and prescribing error rate. Use of CPOE and pharmacist intervention reduced prescribing errors of hospital discharge orders.
Heed J, Klein S, Slee A, et al. Br J Clin Pharmacol. 2022;88:3351-3359.
Hospitals in the US can evaluate the safety of their computerized provider order entry using a simulation tool such as the one provided by the Leapfrog Group. This study developed a similar simulation tool for use in the UK. Study participants rated 178 clinical scenarios for likelihood of occurrence, level of associated harm, and likelihood of harm. One hundred and thirty-one extreme or high-risk prescribing scenarios were developed and will be used to create the evaluation tool.
Pueyo-López C, Sánchez-Cuervo M, Vélez-Díaz-Pallarés M, et al. J Oncol Pharm Pract. 2021;27:1588-1595.
Researchers in this study used healthcare failure mode and effect analysis (HFMEA) to identify and reduce errors during chemotherapy preparation. Nine potential failure modes were identified – wrong label, drug, dose, solvent, or volume; non-sterile preparation; incomplete control; improper packaging or labeling, and; break or spill – and the potential causes and effects. Potential approaches to reduce these failure modes include updating the Standard Operating Procedures (SOPs), implementing a bar code system, and using a weight-based control system.
Alshehri GH, Keers RN, Carson-Stevens A, et al. J Patient Saf. 2021;17:341-351.
Medication errors are common in mental health hospitals. This study found medication administration and prescribing were the most common stages of medication error. Staff-, organizational-, patient-, and equipment-related factors were identified as contributing to medication safety incidents.
Koeck JA, Young NJ, Kontny U, et al. Pediatric Drugs. 2021;23:223-240.
Pediatric patients are at risk for medication prescribing errors due to weight-based dosing. This review analyzed 70 interventions aimed at reducing weight-based prescribing errors. Findings indicate that bundled interventions are most effective, and that interventions should include substitute or engineering controls (e.g., computerized provider order entry) along with administrative controls (e.g., expert consultation).
Computerized prescriber (or physician) order entry (CPOE) systems are widely used in healthcare and studies have shown a reduction in medication errors with CPOE. This study focused on whether CPOE systems improved the incidence of chemotherapy-related medication errors. The study included 11 studies in the review but only 8 studies were in the meta-analysis. The authors found that the use of CPOE was associated with an 81% reduction in chemotherapy-related medication errors, indicating that CPOE is a valuable strategy for this patient population.
Polypharmacy in older adults is common and may increase risk of medication-related adverse events. This study found that an intervention combining educational training, tailored health information technology, and a therapy check process improved medication appropriateness in nursing home residents.
Computerized provider order entry (CPOE) can prevent prescribing errors, but patient safety threats persist. Based on qualitative interviews with multidisciplinary prescribers, the authors identified several issues related to CPOE interacting within a complex prescribing environment, including alert fatigue, remote prescribing, and default auto-population of dosages.
Delvaux N, Piessens V, Burghgraeve TD, et al. Implement Sci. 2020;15:100.
Clinical decision support systems (CDSS) and computerized physician order entry (CPOE) have the potential to improve patient safety. This randomized trial evaluated the impact of integrating CDSS into CPOE among general practitioners in Belgium. The intervention improved appropriateness and decreased volume of laboratory test ordering and did not show any increases in diagnostic errors.
Corny J, Rajkumar A, Martin O, et al. J Am Med Inform Assoc. 2020;27:1695–1704.
Machine learning can improve the accuracy of clinical decision support (CDS) tools. This single-site study used data from the electronic health record (EHR) and clinical pharmacist review to test the accuracy of a hybrid CDS system to identify prescriptions with high risk of medication error. The machine-learning based approach was more accurate than existing techniques such as the traditional CDS system and can improve the reliability of prescription checks in an inpatient setting.
Kuitunen SK, Niittynen I, Airaksinen M, et al. J Patient Saf. 2021;17:e1669-e1680.
The objective of this systematic review was to identify systemic defenses (such as barcode scanning) to confirm drug and patient identity, clinical decision systems, and smart infusion pumps) to prevent in-hospital intravenous (IV) medication errors. Of the 46 included studies, most discussed systemic defenses related to drug administration; fewer discussed defenses during prescribing, preparation, treatment monitoring and dispensing. Closed loop medication management and smart pumps were the most common systemic defenses examined in the included studies; the authors identify a need for further studies exploring the effectiveness of different combinations of systemic defenses.
Howlett MM, Butler E, Lavelle KM, et al. Appl Clin Inform. 2020;11.
Using a pre-post approach, this study assessed the impact of implementing electronic prescribing and smart pump-facilitated standard concentration infusions on medication errors in a pediatric intensive care unit (PICU). The overall error rates were similar before and after implementation but the error types changed before and after implementation of these tools. After implementation, lack of clarity, incomplete orders and wrong unit errors were reduced but dosing errors, altered orders and duplicate errors increased. Pre-implementation, 78% of errors were deemed preventable by electronic prescribing and smart-pumps; post-implementation 27% of errors were attributed to the technology and would not have occurred if the order was not electronically created or administered via the smart-pump.
Farre A, Heath G, Shaw K, et al. BMJ Qual Saf. 2019;28:1021-1031.
This systematic review synthesizes the qualitative evidence about electronic prescribing. From 79 included studies, the study team identified a series of frontline implementation challenges such as perceived inefficiencies and lack of technical support. Benefits of electronic prescribing included improved quality, safety, documentation, and enhanced reputation. The authors conclude that computerized provider order entry catalyzes far-ranging organizational change and could benefit from preimplementation, proactive change management.
Reinhardt H, Otte P, Eggleton AG, et al. Cancer. 2019;125:1547-1557.
Chemotherapy medications often have complex dosing, which in turn is associated with prescribing errors. This single-center observational study retrospectively examined chemotherapy ordering errors that had been intercepted by a pharmacist-led chemotherapy safety team. Although the overall rate of errors was only 2%, most were deemed clinically relevant. Because a significant proportion of the identified errors were amenable to computerized decision support, the hospital implemented an advanced computerized provider order entry module to reduce prescribing errors in an automated fashion. Noting that many errors were not rule-based, the authors conclude that pharmacist-led error checking remains critical for error prevention. A WebM&M commentary discussed how pharmacist involvement can help improve medication safety.
Vélez-Díaz-Pallarés M, Pérez-Menéndez-Conde C, Bermejo-Vicedo T. Am J Health Syst Pharm. 2018;75:1909-1921.
Use of computerized provider order entry (CPOE) is increasingly widespread. This systematic review found that while CPOE with clinical decision support reduced certain medication errors associated with prescribing, CPOE led to the introduction of new errors.
Puaar SJ, Franklin BD. BMJ Qual Saf. 2018;27:529-538.
Computerized provider order entry (CPOE) has vastly improved medication safety when compared to handwritten orders. However, even with CPOE, medication ordering errors are common. This qualitative study used a human factors approach to characterize electronic prescribing errors, which were primarily due to CPOE system design, organizational implementation decisions, and individual prescribing behaviors. A PSNet perspective assessed lessons learned about electronic health record safety.
Pontefract SK, Hodson J, Slee A, et al. BMJ Qual Saf. 2018;27:725-736.
Although computerized provider order entry (CPOE) reliably reduces medication errors, clinical decision support has more varied impact on safety outcomes. System complexity, insufficient emphasis on human factors engineering, and alert fatigue limit utility of clinical decision support. This study rigorously examined medication error rates before and after implementation of CPOE with clinical decision support at three hospitals in England. In a sample of 2422 patients, the overall error rate decreased 20%. At one hospital, the error rate did not change because an increase in a specific insulin prescribing error counterbalanced all other error reduction. All three hospitals implemented clinical decision support, but the type, nature, and efficacy varied markedly, even between the two systems implementing the same CPOE. A PSNet perspective synthesized lessons for assessing electronic health record safety as a whole.
Tolley CL, Forde NE, Coffey KL, et al. Journal of the American Medical Informatics Association. 2017;25.
This systematic review of medication errors in pediatrics settings with computerized provider order entry identified key vulnerabilities in electronic prescribing. Lack of drug dosing alerts, inappropriate alerting, dropdown menu option errors, and overarching problems such as the lack of appropriate dosing choices for specific medications contributed to errors across the included studies. The authors call for more advanced decision support to address these concerns.
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