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'''Health information exchange and patient safety- Another review
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'''Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors'''
 +
Ross Koppel, Joshua P. Metlay, et al.
  
David C. Kaelber, David W. Bates
+
Hospital computerized physician order entry (CPOE) systems are widely regarded as the technical solution to medication ordering errors, the largest identified source of preventable hospital medical error. Published studies report that CPOE reduces medication errors up to 81%. Few researchers, however, have focused on the existence or types of medication errors facilitated by CPOE. The authors undertook a comprehensive, multimethod study of CPOE-related factors that enhance risk of prescription errors.
'''
+
----
+
  
One of the most promising advantages for health information exchange (HIE) is improved patient safety. Up to 18% of the patient safety errors generally and as many as 70% of adverse drug events could be eliminated if the right information about the right patient available at the right time. The authors discuss a variety of areas in which HIE can impact patient safety. They also briefly discuss HIE and decreased patient safety as well as standards and completeness of information for HIE and patient safety.
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'''METHODS'''
  
'''A. Health information exchange and increased patient safety'''
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'''Design'''
 +
They performed a quantitative and qualitative study incorporating structured interviews with house staff, pharmacists, nurses, nurse-managers, attending physicians, and information technology managers. The Qualitative research was iterative and interactive
 +
'''Setting'''
 +
They studied a major urban tertiary-care teaching hospital with 750 beds, 39000 annual discharges, and a widely used CPOE system (TDS) operational there from 1997 to 2004.
 +
'''Data Collection'''
 +
1-Intensive One-on-One House Staff Interviews. 2-Focus Groups.3-Expert Interviews.4-Shadowing and Observation.5-Survey.
  
'''1. Improved medication information processing'''
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'''RESULTS'''
The authors divide HIE’s impact on medication information processing into five subsections 1.1. Drug-allergy information processing This involves checking drugs against known patient-specific drug allergies before the drugs are given to the patient. 1.2. Drug–dose information processing (1) Being sure that the individual dose, dosing frequency, and total duration of medication fall within accepted general standards. (2) taking into account patient specific information such as patient age (geriatric dosing), weight (pediatric dosing), and creatinine clearance (renal dosing). 1.3. Drug–drug information processing (1) Adding an additional medication(s) to a patient’s other medications. (2) Duplicate pharmacological class checking. (3) When one medication is being added that could indicate the addition of another medication for improved patient safety. 1.4. Drug-diagnosis information processing. (1) Taking into account medical conditions and contraindications that would affect drug dosing or administration at all. (2) Checking if the drug being prescribed is indicated for any of a patient’s diagnoses. This would help eliminate inappropriate sound-alike/look-alike medications from being prescribed such as clonidine and klonopine. 1.5. Drug–gene information processing. As gene analysis and pharamocogenomics becomes more developed, the ability to interchange drug information and patient-specific genomic information will become increasing important for patient safety.
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'''2. Improved laboratory information processing'''
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The study identified 22 previously unexplored medication-error sources that users report to be facilitated by CPOE. They group these as:
(1) Helping to ensure that indicated lab testing is ordered (2) helping to guarantee that lab test results (especially abnormal results) are appropriately followed up on. HIE is particularly critical in this process in this era of few in-office tests, many ‘‘send-out’’ tests, and numerous independent laboratories.
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'''3. Improved radiology information processing'''
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'''A-Information Errors: Fragmentation and Systems Integration Failure.'''
Typically the provider ordering an imaging study is different from the provider interpreting the imaging study. Therefore, health information has to be exchanged between these two health professionals for the radiology study to electively ordered, interpreted, and to ensure appropriate follow-up of abnormal radiology findings.
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'''4. Improved communication among providers'''
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'''1- Assumed Dose Information.'''
When different primary care providers and/or subspecialists are managing different medical issues, effective information sharing is critical.
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House staff often rely on CPOE displays to determine minimal effective or usual doses. The dosages listed in the CPOE display, however, are based on the pharmacy’s warehousing and purchasing decisions, not clinical guidelines.
 +
'''2-Medication Discontinuation Failures'''
 +
Ordering new or modifying existing medications is usually a separate process from canceling (“discontinuing”) an existing medication. Without discontinuing the current dose, physicians can increase or decrease medication, add new but duplicative medication, and add conflicting medication.
 +
'''3-Procedure-Linked Medication Discontinuation Faults.'''
 +
Procedures and certain tests are often accompanied by medications. If procedures are canceled or postponed, no software link automatically cancels medications.
 +
'''4-Immediate Orders and Give-as-Needed Medication Discontinuation Faults.'''  
 +
NOW (immediate) and PRN (give as needed) orders may not enter the usual medication schedule. Failure to chart or cancel can result in unintended medications on subsequent days or reordering (duplications) on the same day.
 +
'''5-Antibiotic Renewal Failure'''
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Antibiotics are generally approved for 3 days. Before the third day, house staff should request continuation or modification. No warning is integrated into the CPOE system, and ordering gaps expand until noticed. Some unintentional “gaps” continue indefinitely because it is unknown whether antibiotics were intentionally halted.
 +
'''6-Diluent Options and Errors'''
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A recent CPOE innovation requires house staff to specify diluents (e.g., saline solution) for administering antibiotics. Many house staff are unaware of impermissible combinations.
 +
'''7-Allergy Information Delay'''
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CPOE provides feedback on drug allergies, but only after medications are ordered.
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'''8-Conflicting or Duplicative Medications'''
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The CPOE system does not display information available on other hospital systems. For example, only the pharmacy’s computer provides drug interaction and lifetime limit warnings.
  
'''5. Improved communication between patients and providers'''
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'''B-Human-Machine Interface Flaws: Machine Rules That Do Not Correspond to Work Organization or Usual Behaviors'''
Examples include patients checking PHRs for errors in their medical history, adding additional valuable information into their medical records, following up on their own test results, reviewing medications and other healthcare instructions, and being able to communicate more quickly with healthcare providers when they think their safety may be at risk. PHRs may also allow providers to more quickly and more accurately provide information to their patients, which should improve patient safety.
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'''6. Improved public health information processing'''
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'''1-Patient Selection'''
A rapidly growing area of HIE is public health informatics. Patient safety could be greatly enhanced through this growth. Opportunities for improved patient safety in this area include post-marketing drug surveillance, infectious disease surveillance, biohazard surveillance, and environmental exposure surveillance.  
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It is easy to select the wrong patient file because names and drugs are close together, the font is small, names are grouped alphabetically and most critical here, patients’ names do not appear on all screens.
 
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'''2-Wrong Medication Selection.'''  
'''B. Health information exchange and decreased patient safety'''
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A patient’s medication information is seldom synthesized on 1 screen. Up to 20 screens might be needed to see all of a patient’s medications, increasing the likelihood of selecting a wrong medication.
 
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'''3-Unclear Log On/Log Off'''
Increasing the level of HIE could reduce patient safety in a variety of ways, for example, if incorrect patient-specific information were made available to providers, if one patient’s information was believed to be that of another, if there were errors in translating information between one system and others or if implementation of HIE slowed systems to a significant degree, since delays can affect safety. Those who are evaluating HIE should be alert to these and other unintended consequences of implementation of HIE.
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Physician scan order medications at computer terminals not yet “logged out” by the previous physician, which can result in either unintended patients receiving medication or patients not receiving the intended medication.
 
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'''4-Failure to Provide Medications After Surgery.'''
'''C. Standards for health information exchange and patient safety'''
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When patients under go surgery, CPOE cancels their previous medications. When surgeons order new or renewed medications, however, the orders are “suspended” (not sent to the pharmacy) until “activated” by postanesthesia-care nurses. But these “activations” still do not dispense medications. Physicians must reenter CPOE and reactivate each previously ordered medication.  
 
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'''5-Postsurgery “Suspended” Medications.'''
For robust, efficient HIE, standards must be developed dictating the type and content of information to be exchanged. A prototypical example of this is the near ubiquitous proliferation of PACS (Picture Archive and Communication Systems).
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Physicians ordering medications for postoperative patients whom they actually observe on hospital floors can be deceived by patients’ real location vs. patients’ computer-listed location. If patients were not logged out of postanesthesia care, the CPOE will not process medication orders, labeling them “suspended.” Physicians must renegotiate the CPOE and resubmit orders for patients to receive postsurgical medications.
'''
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'''6-Loss of Data, Time, and Focus When CPOE Is Nonfunctional.'''
D. Completeness of information for health information exchange and patient safety'''
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CPOE is shutdown for periodic maintenance, and crashes are common. Backup systems prevent loss of data previously entered. However, orders being entered when the system crashes are lost and cannot be reentered until the system is restarted. House staff reported that the
 
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'''7-Sending Medications to Wrong Rooms When the Computer System Has Shut Down.'''
Another challenge is the completeness of the HIE in order to gain the maximum benefits.
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When a patient is moved within the hospital during the system downtime.
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'''8-Late-in-Day Orders Lost for 24 Hours.'''
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When patients leave surgery or are admitted late in the day, medications and laboratory orders might be requested for “tomorrow” at, for example, 7 AM. By the time the intern enters the orders, however, it might already be “tomorrow” (i.e., after midnight). Therefore, patients do not receive medications or tests for an extra day.
 +
'''9-Role of Charting Difficulties in Inaccurate and Delayed Medication Administration.'''
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Nurses are required to record (chart) administration of medications contemporaneously. However, this requires time.
 +
'''10-Inflexible Ordering Screens, Incorrect Medications.'''
  
 
'''Conclusions'''
 
'''Conclusions'''
 +
 +
In this study, it was found that a leading CPOE system often facilitated medication error risks, with many reported to occur frequently. As CPOE systems are implemented, clinicians and hospitals must attend to errors that these systems cause in addition to errors that they prevent.
  
As more and more health care information becomes digital, the potential for HIE to improve patient safety will grow, and it is already robust. One challenge will be to develop healthcare systems capable of processing and utilizing the dramatic increase in information. Only then will the potential of improved patient safety through enhanced HIE be realized because we will have increased the percent age of time that the right information is presented to the right person at the right time so that the right healthcare decision can be made.
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'''Limitations'''
 
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'''Strength and limitation'''
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As the authors discuss the possible areas where HIE can improve patient safety they do this taking into account the most basic features at first then discuss other advanced features that may be achieved as the HIE and HIT  become more developed. However they didn’t discuss how we cloud evaluate the effectiveness of the HIE in these areas. Also they didn’t give much details upon the role of HIE in the public heath although it is a main and huge area where the HIE can help in improving the patient safety.
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The study conducted at only 1 hospital, examined only 1 CPOE system and the finding are not t from random house staff samples. So the errors discussed here may not be widely generalizable. Most of these CPOE facilitated errors can be easily corrected and avoided during the development and implementation of the system.  
  
reviewed by Ahmed Mahmoud.
+
reviewed by Ahmed Mahmoud

Latest revision as of 22:01, 30 March 2008

Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors Ross Koppel, Joshua P. Metlay, et al.

Hospital computerized physician order entry (CPOE) systems are widely regarded as the technical solution to medication ordering errors, the largest identified source of preventable hospital medical error. Published studies report that CPOE reduces medication errors up to 81%. Few researchers, however, have focused on the existence or types of medication errors facilitated by CPOE. The authors undertook a comprehensive, multimethod study of CPOE-related factors that enhance risk of prescription errors.

METHODS

Design They performed a quantitative and qualitative study incorporating structured interviews with house staff, pharmacists, nurses, nurse-managers, attending physicians, and information technology managers. The Qualitative research was iterative and interactive Setting They studied a major urban tertiary-care teaching hospital with 750 beds, 39000 annual discharges, and a widely used CPOE system (TDS) operational there from 1997 to 2004. Data Collection 1-Intensive One-on-One House Staff Interviews. 2-Focus Groups.3-Expert Interviews.4-Shadowing and Observation.5-Survey.

RESULTS

The study identified 22 previously unexplored medication-error sources that users report to be facilitated by CPOE. They group these as:

A-Information Errors: Fragmentation and Systems Integration Failure.

1- Assumed Dose Information. House staff often rely on CPOE displays to determine minimal effective or usual doses. The dosages listed in the CPOE display, however, are based on the pharmacy’s warehousing and purchasing decisions, not clinical guidelines. 2-Medication Discontinuation Failures Ordering new or modifying existing medications is usually a separate process from canceling (“discontinuing”) an existing medication. Without discontinuing the current dose, physicians can increase or decrease medication, add new but duplicative medication, and add conflicting medication. 3-Procedure-Linked Medication Discontinuation Faults. Procedures and certain tests are often accompanied by medications. If procedures are canceled or postponed, no software link automatically cancels medications. 4-Immediate Orders and Give-as-Needed Medication Discontinuation Faults. NOW (immediate) and PRN (give as needed) orders may not enter the usual medication schedule. Failure to chart or cancel can result in unintended medications on subsequent days or reordering (duplications) on the same day. 5-Antibiotic Renewal Failure Antibiotics are generally approved for 3 days. Before the third day, house staff should request continuation or modification. No warning is integrated into the CPOE system, and ordering gaps expand until noticed. Some unintentional “gaps” continue indefinitely because it is unknown whether antibiotics were intentionally halted. 6-Diluent Options and Errors A recent CPOE innovation requires house staff to specify diluents (e.g., saline solution) for administering antibiotics. Many house staff are unaware of impermissible combinations. 7-Allergy Information Delay CPOE provides feedback on drug allergies, but only after medications are ordered. 8-Conflicting or Duplicative Medications The CPOE system does not display information available on other hospital systems. For example, only the pharmacy’s computer provides drug interaction and lifetime limit warnings.

B-Human-Machine Interface Flaws: Machine Rules That Do Not Correspond to Work Organization or Usual Behaviors

1-Patient Selection It is easy to select the wrong patient file because names and drugs are close together, the font is small, names are grouped alphabetically and most critical here, patients’ names do not appear on all screens. 2-Wrong Medication Selection. A patient’s medication information is seldom synthesized on 1 screen. Up to 20 screens might be needed to see all of a patient’s medications, increasing the likelihood of selecting a wrong medication. 3-Unclear Log On/Log Off Physician scan order medications at computer terminals not yet “logged out” by the previous physician, which can result in either unintended patients receiving medication or patients not receiving the intended medication. 4-Failure to Provide Medications After Surgery. When patients under go surgery, CPOE cancels their previous medications. When surgeons order new or renewed medications, however, the orders are “suspended” (not sent to the pharmacy) until “activated” by postanesthesia-care nurses. But these “activations” still do not dispense medications. Physicians must reenter CPOE and reactivate each previously ordered medication. 5-Postsurgery “Suspended” Medications. Physicians ordering medications for postoperative patients whom they actually observe on hospital floors can be deceived by patients’ real location vs. patients’ computer-listed location. If patients were not logged out of postanesthesia care, the CPOE will not process medication orders, labeling them “suspended.” Physicians must renegotiate the CPOE and resubmit orders for patients to receive postsurgical medications. 6-Loss of Data, Time, and Focus When CPOE Is Nonfunctional. CPOE is shutdown for periodic maintenance, and crashes are common. Backup systems prevent loss of data previously entered. However, orders being entered when the system crashes are lost and cannot be reentered until the system is restarted. House staff reported that the 7-Sending Medications to Wrong Rooms When the Computer System Has Shut Down. When a patient is moved within the hospital during the system downtime. 8-Late-in-Day Orders Lost for 24 Hours. When patients leave surgery or are admitted late in the day, medications and laboratory orders might be requested for “tomorrow” at, for example, 7 AM. By the time the intern enters the orders, however, it might already be “tomorrow” (i.e., after midnight). Therefore, patients do not receive medications or tests for an extra day. 9-Role of Charting Difficulties in Inaccurate and Delayed Medication Administration. Nurses are required to record (chart) administration of medications contemporaneously. However, this requires time. 10-Inflexible Ordering Screens, Incorrect Medications.

Conclusions

In this study, it was found that a leading CPOE system often facilitated medication error risks, with many reported to occur frequently. As CPOE systems are implemented, clinicians and hospitals must attend to errors that these systems cause in addition to errors that they prevent.

Limitations

The study conducted at only 1 hospital, examined only 1 CPOE system and the finding are not t from random house staff samples. So the errors discussed here may not be widely generalizable. Most of these CPOE facilitated errors can be easily corrected and avoided during the development and implementation of the system.

reviewed by Ahmed Mahmoud

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