Junior doctors’ prescribing work after-hours and the impact of computerized decision support

Prescribers’ reported acceptance and use of drug-drug interaction alerts: An Australian survey

Drug-drug interaction (DDI) alerts are frequently included in electronic medical record (eMR) systems to provide users with relevant information and guidance at the point of care. In this study, we aimed to examine views of DDI alerts among prescribers, including junior doctors, registrars and senior doctors, across Australia. A validated survey for assessing prescribers’ reported acceptance and use of DDI alerts was distributed among researcher networks and in newsletters. Fifty useable responses were received, more than half ( n = 28) from senior doctors. Prescribers at all levels expected DDI alerts to improve performance but junior doctors reported that this was at a high cost, with respect to time and effort. Senior doctors and registrars reported rarely reading alerts and rarely changing prescribing decisions based on alerts. Respondents identified a number of problems with current alerts including limited relevance, repetition, and poor design, highlighting some clear areas for alert improvement.

Characteristics of pharmacist's interventions triggered by prescribing errors related to computerised physician order entry in French hospitals: a cross-sectional observational study

OBJECTIVES

Computerised physician order entry (CPOE) systems facilitate the review of medication orders by pharmacists. Reports have emerged that show conception flaws or the misuse of CPOE systems generate prescribing errors. We aimed to characterise pharmacist interventions (PIs) triggered by prescribing errors identified as system-related errors (PISREs) in French hospitals.

DESIGN

This was a cross-sectional observational study based on PIs prospectively documented in the Act-IP observatory database from January 2014 to December 2018.

SETTING

PISREs from 319 French computerised healthcare facilities were analysed.

PARTICIPANTS

Among the 319 French hospitals, 232 (72.7%) performed SRE interventions, involving 652 (51%) pharmacists.

RESULTS

Among the 331 678 PIs recorded, 27 058 were qualified as due to SREs (8.2%). The main drug-related problems associated with PISREs were supratherapeutic (27.5%) and subtherapeutic dosage (17.2%), non-conformity with guidelines/contraindications (22.4%) and improper administration (17.9%). The PI prescriber acceptation rate was 78.9% for SREs vs 67.6% for other types of errors. The PISRE ratio was estimated relative to the total number of PIs. Concerning the certification status of CPOE systems, the PISRE ratio was 9.4% for non-certified systems vs 5.5% for certified systems (p<0.001). The PISRE ratio for senior pharmacists was 9.2% and that for pharmacy residents 5.4% (p<0.001). Concerning prescriptions made by graduate prescribers and those made by residents, the PISRE ratio was 8.4% and 7.8%, respectively (p<0.001).

CONCLUSION

Computer-related prescribing errors are common. The PI acceptance rate by prescribers was higher than that observed for PIs that were not CPOE related. This suggests that physicians consider the potential clinical consequences of SREs for patients to be more frequently serious than interventions unrelated to CPOE. CPOE medication review requires continual pharmacist diligence to catch these errors. The significantly lower PISRE ratio for certified software should prompt patient safety agencies to undertake studies to identify the safest software and discard software that is potentially dangerous.

The appropriateness of clinical decision support systems alerts in supporting clinical workflows: A systematic review

A CDSS generates a high number of inappropriate alerts that interrupt the clinical workflow. As a result, clinicians silence, disable, or ignore alerts, thereby undermining patient safety. Therefore, the effectiveness and appropriateness of CDSS alerts need to be evaluated. A systematic review was carried out to identify the factors that affect CDSS alert appropriateness in supporting clinical workflow. Seven electronic databases (PubMed, Scopus, ACM, Science Direct, IEEE, Ovid Medline, and Ebscohost) were searched for English language articles published between 1997 and 2018. Seventy six papers met the inclusion criteria, of which 26, 24, 15, and 11 papers are retrospective cohort, qualitative, quantitative, and mixed-method studies, respectively. The review highlights various factors influencing the appropriateness and efficiencies of CDSS alerts. These factors are categorized into technology, human, organization, and process aspects using a combination of approaches, including socio-technical framework, five rights of CDSS, and Lean. Most CDSS alerts were not properly designed based on human factor methods and principles, explaining high alert overrides in clinical practices. The identified factors and recommendations from the review may offer valuable insights into how CDSS alerts can be designed appropriately to support clinical workflow.

Challenges and Best Practices in Ethical Review of Human and Organizational Factors Studies in Health Technology: a Synthesis of Testimonies

OBJECTIVE

Human and Organizational Factors (HOF) studies in health technology involve human beings and thus require Institutional Review Board (IRB) approval. Yet HOF studies have specific constraints and methods that may not fit standard regulations and IRB practices. Gaining IRB approval may pose difficulties for HOF researchers. This paper aims to provide a first overview of HOF study challenges to get IRB review by exploring differences and best practices across different countries.

METHODS

HOF researchers were contacted by email to provide a testimony about their experience with IRB review and approval. Testimonies were thematically analyzed and synthesized to identify and discuss shared themes.

RESULTS

Researchers from seven European countries, Argentina, Canada, Australia, and the United States answered the call. Four themes emerged that indicate shared challenges in legislation, IRB inefficiencies and inconsistencies, general regulation and costs, and lack of HOF study knowledge by IRB members. We propose a model for IRB review of HOF studies based on best practices.

CONCLUSION

International criteria are needed that define low and high-risk HOF studies, to allow identification of studies that can undergo an expedited (or exempted) process from those that need full IRB review. Enhancing IRB processes in such a way would be beneficial to the conduct of HOF studies. Greater knowledge and promotion of HOF methods and evidence-based HOF study designs may support the evolving discipline. Based on these insights, training and guidance to IRB members may be developed to support them in ensuring that appropriate ethical issues for HOF studies are considered.

Interventions to improve antimicrobial prescribing of doctors in training (IMPACT): a realist review

Background

Interventions to improve the antimicrobial prescribing practices of doctors have been implemented widely to curtail the emergence and spread of antimicrobial resistance, but have been met with varying levels of success.

Objectives

This study aimed to generate an in-depth understanding of how antimicrobial prescribing interventions ‘work’ (or do not work) for doctors in training by taking into account the wider context in which prescribing decisions are enacted.

Design

The review followed a realist approach to evidence synthesis, which uses an interpretive, theory-driven analysis of qualitative, quantitative and mixed-methods data from relevant studies.

Setting

Primary and secondary care.

Participants

Not applicable.

Interventions

Studies related to antimicrobial prescribing for doctors in training.

Main outcome measures

Not applicable.

Data sources

EMBASE (via Ovid), MEDLINE (via Ovid), MEDLINE In-Process & Other Non-Indexed Citations (via Ovid), PsycINFO (via Ovid), Web of Science core collection limited to Science Citation Index Expanded (SCIE) and Conference Proceedings Citation Index – Science (CPCI-S) (via Thomson Reuters), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, the Health Technology Assessment (HTA) database (all via The Cochrane Library), Applied Social Sciences Index and Abstracts (ASSIA) (via ProQuest), Google Scholar (Google Inc., Mountain View, CA, USA) and expert recommendations.

Review methods

Clearly bounded searches of electronic databases were supplemented by citation tracking and grey literature. Following quality standards for realist reviews, the retrieved articles were systematically screened and iteratively analysed to develop theoretically driven explanations. A programme theory was produced with input from a stakeholder group consisting of practitioners and patient representatives.

Results

A total of 131 articles were included. The overarching programme theory developed from the analysis of these articles explains how and why doctors in training decide to passively comply with or actively follow (1) seniors’ prescribing habits, (2) the way seniors take into account prescribing aids and seek the views of other health professionals and (3) the way seniors negotiate patient expectations. The programme theory also explains what drives willingness or reluctance to ask questions about antimicrobial prescribing or to challenge the decisions made by seniors. The review outlines how these outcomes result from complex inter-relationships between the contexts of practice doctors in training are embedded in (hierarchical relationships, powerful prescribing norms, unclear roles and responsibilities, implicit expectations about knowledge levels and application in practice) and the mechanisms triggered in these contexts (fear of criticism and individual responsibility, reputation management, position in the clinical team and appearing competent). Drawing on these findings, we set out explicit recommendations for optimal tailoring, design and implementation of antimicrobial prescribing interventions targeted at doctors in training.

Limitations

Most articles included in the review discussed hospital-based, rather than primary, care. In cases when few data were available to fully capture all the nuances between context, mechanisms and outcomes, we have been explicit about the strength of our arguments.

Conclusions

This review contributes to our understanding of how antimicrobial prescribing interventions for doctors in training can be better embedded in the hierarchical and interprofessional dynamics of different health-care settings.

Future work

More work is required to understand how interprofessional support for doctors in training can contribute to appropriate prescribing in the context of hierarchical dynamics.

Study registration

This study is registered as PROSPERO CRD42015017802.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Social and professional influences on antimicrobial prescribing for doctors-in-training: a realist review

Background

Antimicrobial resistance has led to widespread implementation of interventions for appropriate prescribing. However, such interventions are often adopted without an adequate understanding of the challenges facing doctors-in-training as key prescribers.

Methods

The review followed a realist, theory-driven approach to synthesizing qualitative, quantitative and mixed-methods literature. Consistent with realist review quality standards, articles retrieved from electronic databases were systematically screened and analysed to elicit explanations of antimicrobial prescribing behaviours. These explanations were consolidated into a programme theory drawing on social science and learning theory, and shaped though input from patients and practitioners.

Results

By synthesizing data from 131 articles, the review highlights the complex social and professional dynamics underlying antimicrobial prescribing decisions of doctors-in-training. The analysis shows how doctors-in-training often operate within challenging contexts (hierarchical relationships, powerful prescribing norms, unclear roles and responsibilities, implicit expectations about knowledge levels, uncertainty about application of knowledge in practice) where they prioritize particular responses (fear of criticism and individual responsibility, managing one's reputation and position in the team, appearing competent). These complex dynamics explain how and why doctors-in-training decide to: (i) follow senior clinicians' prescribing habits; (ii) take (or not) into account prescribing aids, advice from other health professionals or patient expectations; and (iii) ask questions or challenge decisions. This increased understanding allows for targeted tailoring, design and implementation of antimicrobial prescribing interventions.

Conclusions

This review contributes to a better understanding of how antimicrobial prescribing interventions for doctors-in-training can be embedded more successfully in the hierarchical and inter-professional dynamics of different healthcare settings.

Evaluation of an intravenous preparation information system for improving the reconstitution and dilution process

BACKGROUND

There are very few studies reporting the impact of providing intravenous (IV) preparation information on quality use of antimicrobials, particularly regarding their reconstitution and dilution. Therefore, to improve these processes in IV antimicrobial administration, an IV preparation information system (IPIS) was implemented in a hospital.

OBJECTIVE

We aimed to evaluate the effect of improving reconstitution and dilution by implementing an IPIS in the electronic medical record (EMR) system.

METHODS

Prescriptions and activity records of nurses for injectable antimicrobials that required reconstitution and dilution for IV preparation from January 2008 to December 2013 were retrieved from EMR, and assessed based on packaging label information for reconstituting and diluting solutions. We defined proper reconstitution and dilution as occurring when the reconstitution and dilution solutions prescribed were consistent with the nurses' acting records. The types of intervention in the IPIS were as follows: a pop-up alert for proper reconstitution and passive guidance for proper dilution. We calculated the monthly proper reconstitution rate (PRR) and proper dilution rate (PDR) and evaluated the changes in these rates and trends using interrupted time series analyses.

RESULTS

Prior to the initiation of the reconstitution alert and dilution information, the PRR and PDR were 12.7 and 46.1%, respectively. The reconstitution alert of the IPIS rapidly increased the PRR by 41% (p<0.001), after which the PRR decreased by 0.9% (p=0.013) per month after several months. However, there was no significant change in the rate or trend of the PDR during the study period.

CONCLUSIONS

This study demonstrated that the provision of reconstitution alerts by the IPIS contributed to improving the reconstitution process of IV antimicrobial injection administration. However, providing passive information on dilution solutions was ineffective. Furthermore, solutions to ensure the continuous effectiveness of alert systems are warranted and should be actively sought.

Evaluation of Hospital-Wide Computerised Decision Support in an Intensive Care Unit: An Observational Study

We conducted an observational study with interviews in a 12-bed general/neurological intensive care unit (ICU) at a teaching hospital in Sydney, Australia, to determine whether hospital-wide computerised decision support (CDS) embedded in an electronic prescribing system is used and perceived as useful by doctors in an ICU setting. Twenty doctors were shadowed by the observer while on ward rounds (33.6 hours) and non-ward rounds (28 hours) in the ICU. These doctors were also interviewed to explore views of CDS. We found that computerised alerts were triggered frequently in the ICU (n=166, in 59% of orders), less than half of the alerts were read by doctors and only four alerts resulted in a medication order being changed. Pre-written orders were utilised frequently, however reference material was rarely accessed. Interviews with doctors revealed a willingness to use CDS features; however the primary barrier to use was lack of customisation for the ICU setting. Doctors working in the ICU triggered a high number of alerts when prescribing, 40% more alerts than doctors working on general wards of the same hospital. Certain procedures in place in the ICU (e.g. daily microbiology ward rounds) made many alerts redundant in this setting. Lack of customisation for the ICU led to dissatisfaction with CDS and infrequent use of some CDS features.

Effects of monetary reward and punishment on information checking behaviour

Two experiments were conducted to examine whether checking one's own work can be motivated by monetary reward and punishment. Participants were randomly assigned to one of three conditions: a flat-rate payment for completing the task (Control); payment increased for error-free performance (Reward); payment decreased for error performance (Punishment). Experiment 1 (N = 90) was conducted with liberal arts students, using a general data-entry task. Experiment 2 (N = 90) replicated Experiment 1 with clinical students and a safety-critical 'cover story' for the task. In both studies, Reward and Punishment resulted in significantly fewer errors, more frequent and longer checking, than Control. No such differences were obtained between the Reward and Punishment conditions. It is concluded that error consequences in terms of monetary reward and punishment can result in more accurate task performance and more rigorous checking behaviour than errors without consequences. However, whether punishment is more effective than reward, or vice versa, remains inconclusive.

Residents' numeric inputting error in computerized physician order entry prescription

BACKGROUND

Computerized physician order entry (CPOE) system with embedded clinical decision support (CDS) can significantly reduce certain types of prescription error. However, prescription errors still occur. Various factors such as the numeric inputting methods in human computer interaction (HCI) produce different error rates and types, but has received relatively little attention.

OBJECTIVE

This study aimed to examine the effects of numeric inputting methods and urgency levels on numeric inputting errors of prescription, as well as categorize the types of errors.

METHODS

Thirty residents participated in four prescribing tasks in which two factors were manipulated: numeric inputting methods (numeric row in the main keyboard vs. numeric keypad) and urgency levels (urgent situation vs. non-urgent situation). Multiple aspects of participants' prescribing behavior were measured in sober prescribing situations.

RESULTS

The results revealed that in urgent situations, participants were prone to make mistakes when using the numeric row in the main keyboard. With control of performance in the sober prescribing situation, the effects of the input methods disappeared, and urgency was found to play a significant role in the generalized linear model. Most errors were either omission or substitution types, but the proportion of transposition and intrusion error types were significantly higher than that of the previous research. Among numbers 3, 8, and 9, which were the less common digits used in prescription, the error rate was higher, which was a great risk to patient safety.

CONCLUSIONS

Urgency played a more important role in CPOE numeric typing error-making than typing skills and typing habits. It was recommended that inputting with the numeric keypad had lower error rates in urgent situation. An alternative design could consider increasing the sensitivity of the keys with lower frequency of occurrence and decimals. To improve the usability of CPOE, numeric keyboard design and error detection could benefit from spatial incidence of errors found in this study.

iPad use at the bedside: a tool for engaging patients in care processes during ward rounds?

BACKGROUND

Previous work has examined the impact of technology on information sharing and communication between doctors and patients in general practice consultations, but very few studies have explored this in hospital settings.

AIMS

To assess if, and how, senior clinicians use an iPad to share information (e.g. patient test results) with patients during ward rounds and to explore patients' and doctors' experiences of information sharing events.

METHODS

Ten senior doctors were shadowed on ward rounds on general wards during interactions with 525 patients over 77.3 h, seven senior doctors were interviewed and 180 patients completed a short survey.

RESULTS

Doctors reported that information sharing with patients is critical to the delivery of high-quality healthcare, but were not seen to use the iPad to share information with patients on ward rounds. Patients did not think the iPad had impacted on their engagement with doctors on rounds. Ward rounds were observed to follow set routines and patient interactions were brief.

CONCLUSIONS

Although the iPad potentially creates new opportunities for information sharing and patient engagement, the ward round may not present the most appropriate context for this to be done.