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Search results for "Active Errors"

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Web Resource > Multi-use Website

Computer-based Provider Order Entry--CPOE.

ClinfoWiki: The Clinical Informatics Wiki.

This wiki article includes a definition of computer-based provider order entry and other information, such as system elements, implementation tips, and unintended consequences.

Journal Article > Study

Prescription errors related to the use of computerized provider order-entry system for pediatric patients.

Alhanout K, Bun SS, Retornaz K, Chiche L, Colombini N. Int J Med Inform. 2017;103:15-19.

Computerized provider order entry has been shown to decrease adverse drug events, but it can also introduce new medication errors. This retrospective study examined medication ordering errors intercepted by pharmacists for pediatric patients. As with prior studies in pediatrics, this investigation uncovered dosing errors associated with weight-based dosing, including calculation errors and missing weight information. The most common medication associated with errors was acetaminophen, which can cause severe harm if incorrectly dosed. The authors call for improving electronic health record prescribing interfaces, better user training, and enhancing communication among providers to prevent medication errors.

Journal Article > Study

Learning from errors: analysis of medication order voiding in CPOE systems.

Kannampallil TG, Abraham J, Solotskaya A, et al. J Am Med Inform Assoc. 2017 Feb 17; [Epub ahead of print].

Although computerized provider order entry has been found to prevent some medication errors, simulation studies have also demonstrated that electronic prescribing platforms can introduce or fail to prevent medication errors. This retrospective electronic health record analysis examined medication orders that were canceled. Weekend and overnight orders were less likely to be voided than weekday or daytime orders. Pharmacist, nurse, and student orders were more likely to be canceled than physician orders. Comparing the clinician-provided reason for voiding an order with the more comprehensive information in the medical record, physicians found that clinicians' reported reasons for voiding orders were largely inaccurate. The authors suggest there is unrealized potential to characterize medication ordering errors using voided-order data.

Book/Report

Electronically Generated Medication Administration and Electronic Medication Administration Records for the Prevention of Medication Transcription Errors: Review of Clinical Effectiveness and Safety.

Ottawa, ON: Canadian Agency for Drugs and Technologies in Health; 2016.

Use of medication administration technologies can reduce transcription errors. This review examined computerized order entry systems, barcode medication administration systems, and other tools that can prevent medication transcription errors.

Cases & Commentaries

Unexpected Drawbacks of Electronic Order Sets

  • Web M&M

John D. McGreevey III, MD; November 2016

A transition from paper orders to CPOE left out an important safety reminder, resulting in mismanagement of an elderly patient's low potassium and magnesium levels. This led to a fatal arrhythmia. The paper-based electrolyte order set had provided a reminder that magnesium replacement should accompany potassium replacement; however, in the computerized system, a separate order set was necessary for each electrolyte.

Cases & Commentaries

Unintended Consequences of CPOE

  • Spotlight Case
  • CME/CEU
  • Web M&M

Robert L. Wears, MD, PhD; October 2016

While attempting to order a CT scan with only oral contrast for a patient with poor kidney function, an intern ordering a CT for the first time selected "with contrast" from the list, not realizing that meant both oral and intravenous contrast. The patient developed contrast nephropathy.

Newspaper/Magazine Article

Prescribing errors that cause harm.

Rider BB, Gaunt MJ, Grissinger M. PA-PSRS Patient Saf Advis. September 2016;13:81-91.

Prescribing errors can have harmful results. Analyzing prescribing error reports submitted over a 12- year period, this article recommends strategies to reduce risks associated with prescribing, including use of computerized provider order entry systems and standard order sets.

Journal Article > Commentary

Incorporating indications into medication ordering—time to enter the age of reason.

Schiff GD, Seoane-Vazquez E, Wright A. N Engl J Med. 2016;375:306-309.

Clear communication during medication prescribing can enhance safety. This commentary advocates for indications-based prescribing coupled with health information technology as a way to improve team communication, medication reconciliation, and patient education and compliance.

Journal Article > Study

Workarounds to hospital electronic prescribing systems: a qualitative study in English hospitals.

  • Classic

Cresswell KM, Mozaffar H, Lee L, Williams R, Sheikh A. BMJ Qual Saf. 2017;26:542-551.

Computerized provider order entry systems are now widely deployed in hospitals, but their effectiveness at preventing adverse drug events has thus far been less impressive than hoped. Some of this lack of effect may be due to users engaging in workarounds that bypass safety features in order to preserve efficiency. This study used direct observation and interviews to characterize the types of workarounds used by clinical staff at five hospitals in the United Kingdom. Although some workarounds were endorsed by management (such as those to be used if the system was down), most were informal and related to difficulty using the software or to preserve professional roles (for example, senior doctors would delegate prescribing to trainees). Use of workarounds was associated with new potential safety risks, but the authors note that workarounds often represent a reasonable adaptation on the part of frontline staff—especially if the technology itself is not easy to use. They therefore advocate for more formal characterization of workarounds as a part of human factors engineering approaches to improving safety.

Perspectives on Safety > Annual Perspective

Computerized Provider Order Entry and Patient Safety

with commentary by Urmimala Sarkar, MD, and Kaveh Shojania, MD, 2015

Computerized provider order entry is a cornerstone of patient safety efforts, and the increasingly widespread implementation of electronic health records has made it a standard practice in health care. This Annual Perspective summarizes novel findings and research directions in computerized provider order entry in 2015.

Journal Article > Study

Data quality associated with handwritten laboratory test requests: classification and frequency of data-entry errors for outpatient serology tests.

Vecellio E, Maley MW, Toouli G, Georgiou A, Westbrook J. HIM J. 2015;44:7-12.

This audit of handwritten laboratory orders transcribed into electronic information systems found a 10% error rate, most of which were associated with transcription, a known safety vulnerability. These results underscore the benefit of computerized physician order entry for patient safety.

Cases & Commentaries

Amphotericin Toxicity

  • Web M&M

Jerod Nagel, PharmD, and Eric Nguyen; October 2015

A woman who had recently had her left lung removed for aspergilloma presented to the outpatient clinic with pain, redness, and pus draining from her sternotomy site. She was admitted for surgical debridement and prescribed IV liposomal amphotericin B for aspergillus. Hours into the IV infusion, the patient developed nausea, vomiting, sweating, and shivering, and it was discovered that she had been given conventional amphotericin B at the dose intended for the liposomal formulation, representing a 5-fold overdose.

Journal Article > Study

Implementation of a custom alert to prevent medication-timing errors associated with computerized prescriber order entry.

Idemoto LM, Williams BL, Ching JM, Blackmore CC. Am J Health Syst Pharm. 2015;72:1481-1488.

This study examined the effect of a custom alert intended to reduce medication-timing errors associated with introduction of computerized provider order entry, which can lead to too-frequent or missed doses of medications. Using a rigorous interrupted time-series design, researchers found fewer medication-timing errors after implementation of this alert. This work demonstrates how custom alerts developed by clinicians can harness the electronic health record to improve safety.

Journal Article > Study

Implementing computerized provider order entry in acute care hospitals in the United States could generate substantial savings to society.

Nuckols TK, Asch SM, Patel V, et al. Jt Comm J Qual Patient Saf. 2015;41:341-350.

Although computerized physician order entry (CPOE) with decision support is considered to be integral to patient safety, high implementation costs and unintended consequences have led to mixed reactions. This cost-utility analysis compared CPOE with paper ordering among patients in acute care hospitals and concluded that CPOE would yield cost savings and improve health outcomes by reducing preventable adverse drug events. The authors noted that high implementation costs, which often exceed prior estimates, significantly decreased the projected cost savings. A related editorial suggests these findings argue conclusively for universal CPOE with decision support, despite the short-term challenges of implementation.

Journal Article > Study

The impact of a computerized physician order entry system on medical errors with antineoplastic drugs 5 years after its implementation.

Sanchez Cuervo M, Rojo Sanchis A, Pueyo Lopez C, Gomez de Salazar Lopez de Silanes E, Gramage Caro T, Bermejo Vicedo T. J Clin Pharm Ther. 2015 Jul 14; [Epub ahead of print].

Computerized provider order entry (CPOE) has been shown to decrease some adverse drug events (ADEs), but it has also introduced medication errors across multiple settings. This study examined the incidence of ADEs in an inpatient hematology–oncology setting in three timeframes: before CPOE, immediately following implementation, and 5 years later. Although researchers found a significant reduction in ADEs, some errors persisted. These results argue for continued development of decision support to enhance prescribing, particularly in high-risk environments such as inpatient cancer treatment. A past AHRQ WebM&M interview discussed how technology can augment medication safety.

Journal Article > Study

Impact of stewardship interventions on antiretroviral medication errors in an urban medical center: a three year, multi-phase study.

Zucker J, Mittal J, Jen SP, Cheng L, Cennimo D. Pharmacotherapy. 2016;36:245-251.

At baseline, nearly half of patients prescribed antiretroviral treatment for HIV at a university hospital had at least one medication error and 38% had uncorrected errors at discharge. Introducing education and computerized provider order entry only slightly decreased those rates. Launching a stewardship program with prospective audits and feedback in the third year of the study reduced errors at discharge to 12%.

Journal Article > Study

Electronic prescription writing errors in the pediatric emergency department.

Nelson CE, Selbst SM. Pediatr Emerg Care. 2015;31:368-372.

According to this retrospective chart review study, clinically significant prescription errors continued to occur at an alarming rate in a pediatric emergency department, despite the introduction of computerized provider order entry. Emergency medicine residents made more prescribing errors than pediatric residents.

Journal Article > Review

Interventions for reducing medication errors in children in hospital.

Maaskant JM, Vermeulen H, Apampa B, et al. Cochrane Database Syst Rev. 2015;3:CD006208.

Exploring the literature on efforts to reduce medication errors in hospitalized children, this systematic review examined five interventions, including introduction of computerized provider order entry systems, clinical pharmacist participation in the frontline care team, and implementation of barcode medication administration systems. Although the interventions showed some success, none of the studies found a significant reduction in patient harm.

Journal Article > Study

Intercepting wrong-patient orders in a computerized provider order entry system.

Green RA, Hripcsak G, Salmasian H, et al. Ann Emerg Med. 2015;65:679-686.

While computerized physician order entry is expected to significantly reduce adverse drug events, systems must be implemented thoughtfully to avoid facilitating certain types of errors. A forcing function that mandated correct patient identification resulted in a moderate decrease in wrong-patient prescribing errors within a computerized provider order entry system.

Journal Article > Study

Impact of a warning CPOE system on the inappropriate pill splitting of prescribed medications in outpatients.

Hsu CC, Chou CY, Chou CL, et al. PLoS One. 2014;9:e114359.

Clinicians may prescribe split pills for many different reasons, including dosing flexibility and patient affordability; however, this practice presents potential hazards. Splitting medications that are formulated to be extended-release or enteric-coated can lead to possibly dangerous changes in the drug's functionality. This study discusses the introduction of a clinical decision support warning that created a "hard stop" for any time an outpatient clinician attempted to prescribe a split pill for these special formulation medications. The study site was an academic medical center in Taiwan that performs more than 2.5 million ambulatory visits per year. The intervention resulted in a sharp decline in inappropriate medication splitting from a rate of approximately 0.61% to below 0.2%, where it has remained for at least 10 consecutive months. The use of a hard stop order can be controversial, as this method has resulted in unintended consequences in the past. A prior AHRQ WebM&M perspective discussed some of the tensions related to implementing medication decision support systems.

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