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Heitkemper E, Hulse S, Bekemeier B, Schultz M, Whitman G, Turner AM. The Solutions in Health Analytics for Rural Equity Across the Northwest (SHARE-NW) Dashboard for Health Equity in Rural Public Health: Usability Evaluation. JMIR Hum Factors 2024; 11:e51666. [PMID: 38837192 PMCID: PMC11187519 DOI: 10.2196/51666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 03/24/2024] [Accepted: 04/18/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND Given the dearth of resources to support rural public health practice, the solutions in health analytics for rural equity across the northwest dashboard (SHAREdash) was created to support rural county public health departments in northwestern United States with accessible and relevant data to identify and address health disparities in their jurisdictions. To ensure the development of useful dashboards, assessment of usability should occur at multiple stages throughout the system development life cycle. SHAREdash was refined via user-centered design methods, and upon completion, it is critical to evaluate the usability of SHAREdash. OBJECTIVE This study aims to evaluate the usability of SHAREdash based on the system development lifecycle stage 3 evaluation goals of efficiency, satisfaction, and validity. METHODS Public health professionals from rural health departments from Washington, Idaho, Oregon, and Alaska were enrolled in the usability study from January to April 2022. The web-based evaluation consisted of 2 think-aloud tasks and a semistructured qualitative interview. Think-aloud tasks assessed efficiency and effectiveness, and the interview investigated satisfaction and overall usability. Verbatim transcripts from the tasks and interviews were analyzed using directed content analysis. RESULTS Of the 9 participants, all were female and most worked at a local health department (7/9, 78%). A mean of 10.1 (SD 1.4) clicks for task 1 (could be completed in 7 clicks) and 11.4 (SD 2.0) clicks for task 2 (could be completed in 9 clicks) were recorded. For both tasks, most participants required no prompting-89% (n=8) participants for task 1 and 67% (n=6) participants for task 2, respectively. For effectiveness, all participants were able to complete each task accurately and comprehensively. Overall, the participants were highly satisfied with the dashboard with everyone remarking on the utility of using it to support their work, particularly to compare their jurisdiction to others. Finally, half of the participants stated that the ability to share the graphs from the dashboard would be "extremely useful" for their work. The only aspect of the dashboard cited as problematic is the amount of missing data that was present, which was a constraint of the data available about rural jurisdictions. CONCLUSIONS Think-aloud tasks showed that the SHAREdash allows users to complete tasks efficiently. Overall, participants reported being very satisfied with the dashboard and provided multiple ways they planned to use it to support their work. The main usability issue identified was the lack of available data indicating the importance of addressing the ongoing issues of missing and fragmented public health data, particularly for rural communities.
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Affiliation(s)
| | - Scott Hulse
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Betty Bekemeier
- School of Nursing, University of Washington, Seattle, WA, United States
- School of Public Health, University of Washington, Seattle, WA, United States
| | - Melinda Schultz
- School of Nursing, University of Washington, Seattle, WA, United States
| | - Greg Whitman
- School of Nursing, University of Washington, Seattle, WA, United States
| | - Anne M Turner
- School of Public Health, University of Washington, Seattle, WA, United States
- School of Medicine, University of Washington, Seattle, WA, United States
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Wien K, Thern J, Neubert A, Matthiessen BL, Borgwardt S. Reduced prevalence of drug-related problems in psychiatric inpatients after implementation of a pharmacist-supported computerized physician order entry system - a retrospective cohort study. Front Psychiatry 2024; 15:1304844. [PMID: 38654729 PMCID: PMC11035719 DOI: 10.3389/fpsyt.2024.1304844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 03/20/2024] [Indexed: 04/26/2024] Open
Abstract
Introduction In 2021, a computerized physician order entry (CPOE) system with an integrated clinical decision support system (CDSS) was implemented at a tertiary care center for the treatment of mental health conditions in Lübeck, Germany. To date, no study has been reported on the types and prevalence of drug-related problems (DRPs) before and after CPOE implementation in a psychiatric inpatient setting. The aim of this retrospective before-and-after cohort study was to investigate whether the implementation of a CPOE system with CDSS accompanied by the introduction of regular medication plausibility checks by a pharmacist led to a decrease of DRPs during hospitalization and unsolved DRPs at discharge in psychiatric inpatients. Methods Medication charts and electronic patient records of 54 patients before (cohort I) and 65 patients after (cohort II) CPOE implementation were reviewed retrospectively by a clinical pharmacist. All identified DRPs were collected and classified based on 'The PCNE Classification V9.1', the German database DokuPIK, and the 'NCC MERP Taxonomy of Medication Errors'. Results 325 DRPs were identified in 54 patients with a mean of 6 DRPs per patient and 151.9 DRPs per 1000 patient days in cohort I. In cohort II, 214 DRPs were identified in 65 patients with a mean of 3.3 DRPs per patient and 81.3 DRPs per 1000 patient days. The odds of having a DRP were significantly lower in cohort II (OR=0.545, 95% CI 0.412-0.721, p<0.001). The most frequent DRP in cohort I was an erroneous prescription (n=113, 34.8%), which was significantly reduced in cohort II (n=12, 5.6%, p<0.001). During the retrospective in-depth review, more DRPs were identified than during the daily plausibility analyses. At hospital discharge, patients had significantly less unsolved DRPs in cohort II than in cohort I. Discussion The implementation of a CPOE system with an integrated CDSS reduced the overall prevalence of DRPs, especially of prescription errors, and led to a smaller rate of unsolved DRPs in psychiatric inpatients at hospital discharge. Not all DRPs were found by plausibility analyses based on the medication charts. A more interactive and interdisciplinary patient-oriented approach might result in the resolution of more DRPs.
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Affiliation(s)
- Katharina Wien
- Department of Hospital Pharmacy, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Julia Thern
- Department of Hospital Pharmacy, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Anika Neubert
- Department of Hospital Pharmacy, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Britta-Lena Matthiessen
- Department of Psychiatry and Psychotherapy, Center for Integrative Psychiatry, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Stefan Borgwardt
- Department of Psychiatry and Psychotherapy, Center for Integrative Psychiatry, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
- Department of Psychiatry and Psychotherapy, Center of Brain, Behavior and Metabolism, Universität zu Lübeck, Lübeck, Germany
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El Abdouni S, Kalfsvel LS, Rietdijk WJR, Van der Kuy H, van Rosse F. Differences in prescribing errors between electronic prescribing and traditional prescribing among medical students: A randomized pilot study. Br J Clin Pharmacol 2024. [PMID: 38520277 DOI: 10.1111/bcp.16053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/14/2024] [Accepted: 02/22/2024] [Indexed: 03/25/2024] Open
Abstract
AIMS This randomized controlled pilot study aimed to assess the differences in the frequency, type and severity of prescribing errors made by medical students when assessed in an electronic (e-)prescribing system compared to a traditional prescribing method (e.g., typing out a prescription). METHODS Fourth year medical students in the period of 1 November to 31 July 2023, were asked to participate in this single-centre prospective, randomized, controlled intervention study. Participants performed a prescribing assessment in either an e-prescribing system (intervention group) or in a more traditional prescribing platform (control group). The prescriptions were checked for errors, graded and categorized. Differences in prescribing errors, error categories and severity were analysed. RESULTS Out of 334 students, 84 participated in the study. Nearly all participants (98.8%) made 1 or more prescribing errors, primarily involving inadequate information errors. In the intervention group, more participants made prescribing errors involving the prescribed amount (71.4 vs. 19.0%; P < .01), but fewer involving administrative errors (2.4 vs. 19.0%; P = .03). Prescribing-method-specific errors were identified in 4.8 and 40.5% of the intervention and control group, respectively, with significant differences in overlapping errors as well. CONCLUSION This pilot study shows the importance of training e-prescribing competencies in medical curricula, in addition to traditional prescribing methods. It identifies prescribing-method-specific prescribing errors and emphasizes the need for further research to define e-prescribing competencies. Additionally, the need for an accessible real-life-like e-prescribing environment tailored to educators and students is essential for effective learning and incorporation of e-prescribing into medical curricula.
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Affiliation(s)
- Samir El Abdouni
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Laura S Kalfsvel
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Wim J R Rietdijk
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Hugo Van der Kuy
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Floor van Rosse
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Herrmann S, Giesel-Gerstmeier J, Demuth A, Fenske D. We Ask and Listen: A Group-Wide Retrospective Survey on Satisfaction with Digital Medication Software. J Multidiscip Healthc 2024; 17:923-936. [PMID: 38449841 PMCID: PMC10916516 DOI: 10.2147/jmdh.s446896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 02/09/2024] [Indexed: 03/08/2024] Open
Abstract
Purpose Computerized physician order entry (CPOE) and clinical decision support systems (CDSS) are used internationally since the 1980s. These systems reduce costs, enhance drug therapy safety, and improve quality of care. A few years ago, there was a growing effort to digitize the healthcare sector in Germany. Implementing such systems like CPOE-CDSS requires training for effective adoption and, more important, acceptance by the users. Potential improvements for the software and implementation process can be derived from the users' perspective. The implementation process is globally relevant and applicable across professions due to the constant advancement of digitalization. The study assessed the implementation of medication software and overall satisfaction. Methods In an anonymous voluntary online survey, physicians and nursing staff were asked about their satisfaction with the new CPOE-CDSS. The survey comprised single-choice queries on a Likert scale, categorizing into general information, digital medication administration, drug safety, and software introduction. In addition multiple-choice questions are mentioned. Data analysis was performed using Microsoft Office Excel 2016 and GraphPad PRISM 9.5.0. Results Nurses and physicians' satisfaction with the new software increased with usage hours. The software's performance and loading times have clearly had a negative impact, which leads to a low satisfaction of only 20% among physicians and 17% among nurses. 53% of nurses find the program's training period unsuitable for their daily use, while 57% of physicians approve the training's scope for their professional group. Both professions agree that drug-related problems are easier to detect using CPOE-CDSS, with 76% of nurses and 75% of physicians agreeing. The study provides unbiased feedback on software implementation. Conclusion In conclusion, digitizing healthcare requires managing change, effective training, and addressing software functionality concerns to ensure improved medication safety and streamlined processes. Interfaces, performance optimization, and training remain crucial for software acceptance and effectiveness.
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Affiliation(s)
- Saskia Herrmann
- Hospital Pharmacy, Helios Kliniken Gmbh, Berlin, Berlin, Germany
- Department of Pharmaceutical/Medicinal Chemistry, Institute of Pharmacy, Friedrich Schiller University Jena, Jena, Thuringia, Germany
| | | | - Annika Demuth
- Hospital Pharmacy, Helios Kliniken Gmbh, Berlin, Berlin, Germany
| | - Dominic Fenske
- Hospital Pharmacy, Helios Kliniken Gmbh, Berlin, Berlin, Germany
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Videau M, Charpiat B, Conort O, Janoly-Dumenil A, Bedouch P. [Translation and adaptation of a tool prescribing errors related to computerized physician order entry coding to the French hospital background]. ANNALES PHARMACEUTIQUES FRANÇAISES 2023; 81:1054-1071. [PMID: 37356663 DOI: 10.1016/j.pharma.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 05/15/2023] [Accepted: 06/21/2023] [Indexed: 06/27/2023]
Abstract
Prescribing errors related to computerized physician order entry are current and may have serious consequences for patients. They can be detected by pharmacists during prescriptions analysis and lead to pharmacist's interventions. In France, few monocentric studies have studied Pharmacist Interventions triggered by prescribing errors identified as System-Related Errors (PISREs) in French hospitals. However, their respective analysis method prevent any comparison between computerized physician order entry systems in order to identify the safest and rule out the most dangerous. A computerized physician prescribing error related to the software is characterized by its causes, consequences and mechanism of occurrence. US researchers have developed and validated a tool to classify and illustrate these three characteristics. The objectives of this article are to present this tool, to propose a French adaptation and to describe the perspectives analyze and understand prescription errors related to computerized physician order entry based on data of Act-IP©. The adaptation was performed using PISREs extracted from the Act-IP© observatory of the French Society of Clinical Pharmacy. Each item of the codification is illustrated with an example of PI. We are considering a training plan in order to allow wide use of this tool. Once adopted this tool, the next step will be to organize a prospective multicenter study including as many computerized prescription order entry systems as possible. The aim of this study will be identifying the safest systems. Consequently, it will then be possible to have arguments to qualify the most dangerous and thus propose their withdrawal from the market.
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Affiliation(s)
- Manon Videau
- Université Grenoble Alpes, CNRS/TIMC-IMAG UMR5525, 38041, Grenoble, France; Pôle pharmacie, Centre Hospitalier Universitaire Grenoble Alpes, 38043, Grenoble, France; Groupe de travail "Valorisation des Interventions Pharmaceutiques-Act-IP©" de la Société Française de Pharmacie Clinique.
| | - Bruno Charpiat
- Université Grenoble Alpes, CNRS/TIMC-IMAG UMR5525, 38041, Grenoble, France; Département de pharmacie, hôpital Croix Rousse, Hospices civils de Lyon, 69004, Lyon, France; Groupe de travail "Valorisation des Interventions Pharmaceutiques-Act-IP©" de la Société Française de Pharmacie Clinique
| | - Ornella Conort
- Département de pharmacie, hôpital Cochin, Assistance publique-Hôpitaux de Paris, 75879, Paris, France; Groupe de travail "Valorisation des Interventions Pharmaceutiques-Act-IP©" de la Société Française de Pharmacie Clinique
| | - Audrey Janoly-Dumenil
- Département de pharmacie, hôpital Édouard-Herriot, Hospices civils de Lyon, 69003, Lyon, France; EA 4129 P2S Parcours santé systémique, université Claud-Bernard Lyon 1, Université de Lyon, Lyon, France; Groupe de travail "Valorisation des Interventions Pharmaceutiques-Act-IP©" de la Société Française de Pharmacie Clinique
| | - Pierrick Bedouch
- Université Grenoble Alpes, CNRS/TIMC-IMAG UMR5525, 38041, Grenoble, France; Pôle pharmacie, Centre Hospitalier Universitaire Grenoble Alpes, 38043, Grenoble, France; Groupe de travail "Valorisation des Interventions Pharmaceutiques-Act-IP©" de la Société Française de Pharmacie Clinique
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Oms Arias M, Pons Mesquida MÀ, Dehesa Camps R, Abizanda Garcia J, Hermosilla Pérez E, Méndez Boo L. [Does recommending the dosing frequency in the electronic prescription improve its adequacy? Before and after study]. Aten Primaria 2023; 55:102683. [PMID: 37320954 PMCID: PMC10460898 DOI: 10.1016/j.aprim.2023.102683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/11/2023] [Accepted: 05/22/2023] [Indexed: 06/17/2023] Open
Abstract
OBJECTIVE To assess whether reporting the dosing frequency into the prescription module of the Institut Català de la Salut (ICS) primary care electronic clinical workstation improves the dosing frequency's adequacy of the prescriptions. DESIGN Before and after study with non-equivalent control of prescriptions without any change in the dosing frequency. The study periods includes from September 1st, 2019 to February 29th, 2020. LOCATION Primary care setting. PARTICIPANTS Prescriptions issued by ICS General Practitioner, during the study period of those medicines which indications have a single appropriate dosing frequency or mostly appropriate, are included. INTERVENTION Recommendation of the appropriate dosing frequency in the prescription module. MAIN MEASUREMENTS Adequacy defined as the coincidence between the prescribed dosing frequency and the appropriate dosing frequency. RESULTS After the intervention there was a 22.75% increase in prescriptions with adequate dosing frequency. The largest increase occurred in the medicines for the genitourinary system and sex hormones. In absolute terms, the group of anti infective for systemic use is the one that obtained more prescriptions with an adequate dosing frequency between the two periods. CONCLUSIONS The intervention increased the dosing frequency's adequacy leading to improvements in the safety and effectiveness of the treatments. It is evident that the design and implementation of improvements in electronic prescription systems contributes to increasing the quality of the prescription.
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Affiliation(s)
- Míriam Oms Arias
- Unitat de Coordinació i Estratègia del Medicament (UCEM), Institut Català de la Salut, Barcelona, Catalunya, España.
| | - M Àngels Pons Mesquida
- Unitat de Coordinació i Estratègia del Medicament (UCEM), Institut Català de la Salut, Barcelona, Catalunya, España
| | - Rosa Dehesa Camps
- Unitat de Coordinació i Estratègia del Medicament (UCEM), Institut Català de la Salut, Barcelona, Catalunya, España
| | - Judith Abizanda Garcia
- Unitat de Coordinació i Estratègia del Medicament (UCEM), Institut Català de la Salut, Barcelona, Catalunya, España
| | - Eduardo Hermosilla Pérez
- Sistemes d'Informació dels Serveis d'Atenció Primària (SISAP), Institut Català de la Salut, Barcelona, Catalunya, España
| | - Leonardo Méndez Boo
- Sistemes d'Informació dels Serveis d'Atenció Primària (SISAP), Institut Català de la Salut, Barcelona, Catalunya, España
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Batista AM, Gama ZADS, Hernández PJS, Souza D. Quality of prescription writing in Brazilian primary health care. Prim Health Care Res Dev 2023; 24:e49. [PMID: 37522367 PMCID: PMC10466202 DOI: 10.1017/s1463423623000415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/05/2023] [Accepted: 06/12/2023] [Indexed: 08/01/2023] Open
Abstract
OBJECTIVE To evaluate the quality of prescription writing in the context of public primary health care. BACKGROUND Prescription errors are one of the leading patient safety problems in primary care and can be caused by errors in therapeutic decisions or in the quality of prescription writing. METHODS Cross-sectional observational study conducted in a municipality in Northeastern Brazil. The assessment instrument (including 13 indicators and one composite indicator) was applied to a representative sample of drug prescriptions from the 24 Family Health Teams providing Primary Health Care in the municipality, dispensed in January 2021. Estimates of compliance and their 95% confidence intervals and graphical analysis of frequencies are assessed globally and stratified by dispensing units and prescribers. FINDINGS The average composite prescription writing quality on a 0-100 scale was 60.2 (95% CI 57.8-62.6). No quality criteria had 100% compliance. The highest compliance rates were found for 'frequency of administration' (98.9%) and 'identification of the prescriber' (98.9%). On the other hand, 'recorded information on allergy' (0.0%), 'patient's date of birth' (1.7%), 'nonpharmacological recommendations' (1.7%), and 'guidance on the use of the drug' (25%) were the indicators with lower compliance, contributing to 69% of the noncompliances found. The type and frequency of the errors in the quality of prescription writing uncovered in this study confirm the continuing need to tackle this problem to improve patient safety. The results identify priority aspects for interventions and further studies on the quality of prescription writing in the context of Primary Health Care in Brazil.
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Affiliation(s)
- Almária Mariz Batista
- Multicampi School of Medical Sciences, Federal University of Rio Grande do Norte, Caicó, Brazil
- Instituto Nacional de Salud Pública, Cuernavaca, México
| | | | | | - Dyego Souza
- Department of Collective Health, Federal University of Rio Grande do Norte, Natal, Brazil
- Graduate Programme in Health Sciences, Federal University of Rio Grande do Norte, Natal, Brazil
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Jungreithmayr V, Haefeli WE, Seidling HM. Workflow, Time Requirement, and Quality of Medication Documentation with or without a Computerized Physician Order Entry System-A Simulation-Based Lab Study. Methods Inf Med 2023; 62:40-48. [PMID: 37019150 DOI: 10.1055/s-0042-1758631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
BACKGROUND The introduction of a computerized physician order entry (CPOE) system is changing workflows and redistributing tasks among health care professionals. OBJECTIVES The aim of this study is to describe exemplary changes in workflow, to objectify the time required for medication documentation, and to evaluate documentation quality with and without a CPOE system (Cerner® i.s.h.med). METHODS Workflows were assessed either through direct observation and in-person interviews or through semistructured online interviews with clinical staff involved in medication documentation. Two case scenarios were developed consisting of exemplary medications (case 1 = 6 drugs and case 2 = 11 drugs). Physicians and nurses/documentation assistants were observed documenting the case scenarios according to workflows established prior to CPOE implementation and those newly established with CPOE implementation, measuring the time spent on each step in the documentation process. Subsequently, the documentation quality of the documented medication was assessed according to a previously established and published methodology. RESULTS CPOE implementation simplified medication documentation. The overall time needed for medication documentation increased from a median of 12:12 min (range: 07:29-21:10 min) without to 14:40 min (09:18-25:18) with the CPOE system (p = 0.002). With CPOE, less time was spent documenting peroral prescriptions and more time documenting intravenous/subcutaneous prescriptions. For physicians, documentation time approximately doubled, while nurses achieved time savings. Overall, the documentation quality increased from a median fulfillment score of 66.7% without to 100.0% with the CPOE system (p < 0.001). CONCLUSION This study revealed that CPOE implementation simplified the medication documentation process but increased the time spent on medication documentation by 20% in two fictitious cases. This increased time resulted in higher documentation quality, occurred at the expense of physicians, and was primarily due to intravenous/subcutaneous prescriptions. Therefore, measures to support physicians with complex prescriptions in the CPOE system should be established.
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Affiliation(s)
- Viktoria Jungreithmayr
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
- Cooperation Unit Clinical Pharmacy, Heidelberg University, Heidelberg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
- Cooperation Unit Clinical Pharmacy, Heidelberg University, Heidelberg, Germany
| | - Hanna M Seidling
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
- Cooperation Unit Clinical Pharmacy, Heidelberg University, Heidelberg, Germany
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Awad S, Amon K, Baillie A, Loveday T, Baysari MT. Human factors and safety analysis methods used in the design and redesign of electronic medication management systems: A systematic review. Int J Med Inform 2023; 172:105017. [PMID: 36809716 DOI: 10.1016/j.ijmedinf.2023.105017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 01/15/2023] [Accepted: 01/31/2023] [Indexed: 02/11/2023]
Abstract
INTRODUCTION Poorly designed electronic medication management systems (EMMS) or computerized physician order entry (CPOE) systems in hospital settings can result in usability issues and in turn, patient safety risks. As a safety science, human factors and safety analysis methods have potential to support the safe and usable design of EMMS. OBJECTIVE To identify and describe human factors and safety analysis methods that have been used in the design or redesign of EMMS used in hospital settings. MATERIALS AND METHODS A systematic review, following PRISMA guidelines, was conducted by searching online databases and relevant journals from January 2011 to May 2022. Studies were included if they described the practical application of human factors and safety analysis methods to support the design or redesign of a clinician-facing EMMS, or its components. Methods used were extracted and mapped to human centered design (HCD) activities: understanding context of use; specifying user requirements; producing design solutions; and evaluating the design. RESULTS Twenty-one papers met the inclusion criteria. Overall, 21 human factors and safety analysis methods were used in the design or redesign of EMMS with prototyping, usability testing, participant surveys/questionnaires and interviews the most frequent. Human factors and safety analysis methods were most frequently used to evaluate the design of a system (n = 67; 56.3%). Nineteen of 21 (90%) methods used aimed to identify usability issues and/or support iterative design; only one paper utilized a safety-oriented method and one, a mental workload assessment method. DISCUSSION AND CONCLUSION While the review identified 21 methods, EMMS design primarily utilized a subset of available methods, and rarely a method focused on safety. Given the high-risk nature of medication management in complex hospital environments, and the potential for harm due to poorly designed EMMS, there is significant potential to apply more safety-oriented human factors and safety analysis methods to support EMMS design.
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Affiliation(s)
- Selvana Awad
- Biomedical Informatics and Digital Health, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Australia; eHealth NSW, Australia.
| | - Krestina Amon
- Biomedical Informatics and Digital Health, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Australia
| | - Andrew Baillie
- Sydney School of Health Sciences, Faculty of Medicine & Health, The University of Sydney, Australia; Sydney Local Health District, Australia
| | | | - Melissa T Baysari
- Biomedical Informatics and Digital Health, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Australia
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Tolley C, Seymour H, Watson N, Nazar H, Heed J, Belshaw D. Barriers and Opportunities for the Use of Digital Tools in Medicines Optimization Across the Interfaces of Care: Stakeholder Interviews in the United Kingdom. JMIR Med Inform 2023; 11:e42458. [PMID: 36897631 PMCID: PMC10039399 DOI: 10.2196/42458] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 01/05/2023] [Accepted: 01/25/2023] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND People with long-term conditions frequently transition between care settings that require information about a patient's medicines to be transferred or translated between systems. This process is currently error prone and associated with unintentional changes to medications and miscommunication, which can lead to serious patient consequences. One study estimated that approximately 250,000 serious medication errors occur in England when a patient transitions from hospital to home. Digital tools can equip health care professionals with the right information at the right time and place to support practice. OBJECTIVE This study aimed to answer the following questions: what systems are being used to transfer information across interfaces of care within a region of England? and what are the challenges and potential opportunities for more effective cross-sector working to support medicines optimization? METHODS A team of researchers at Newcastle University conducted a qualitative study by performing in-depth semistructured interviews with 23 key stakeholders in medicines optimization and IT between January and March 2022. The interviews lasted for approximately 1 hour. The interviews and field notes were transcribed and analyzed using the framework approach. The themes were discussed, refined, and applied systematically to the data set. Member checking was also performed. RESULTS This study revealed themes and subthemes pertaining to 3 key areas: transfer of care issues, challenges of digital tools, and future hopes and opportunities. We identified a major complexity in terms of the number of different medicine management systems used throughout the region. There were also important challenges owing to incomplete patient records. We also highlighted the barriers related to using multiple systems and their subsequent impact on user workflow, a lack of interoperability between systems, gaps in the availability of digital data, and poor IT and change management. Finally, participants described their hopes and opportunities for the future provision of medicines optimization services, and there was a clear need for a patient-centered consolidated integrated health record for use by all health and care professionals across different sectors, bridging those working in primary, secondary, and social care. CONCLUSIONS The effectiveness and utility of shared records depend on the data within; therefore, health care and digital leaders must support and strongly encourage the adoption of established and approved digital information standards. Specific priorities regarding understanding of the vision for pharmacy services and supporting this with appropriate funding arrangements and strategic planning of the workforce were also described. In addition, the following were identified as key enablers to harness the benefits of digital tools to support future medicines optimization: development of minimal system requirements; enhanced IT system management to reduce unnecessary repetition; and importantly, meaningful and continued collaboration with clinical and IT stakeholders to optimize systems and share good practices across care sectors.
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Affiliation(s)
- Clare Tolley
- School of Pharmacy, Newcastle University, Newcastle upon Tyne, United Kingdom
- Pharmacy Department, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Helen Seymour
- North East and North Cumbria Academic Health Science Network, Newcastle upon Tyne, United Kingdom
| | - Neil Watson
- School of Pharmacy, Newcastle University, Newcastle upon Tyne, United Kingdom
- Pharmacy Department, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Hamde Nazar
- School of Pharmacy, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Jude Heed
- School of Pharmacy, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Dave Belshaw
- North East and North Cumbria Academic Health Science Network, Newcastle upon Tyne, United Kingdom
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Knowledge, Attitude, and Behaviour with Regard to Medication Errors in Intravenous Therapy: A Cross-Cultural Pilot Study. Healthcare (Basel) 2023; 11:healthcare11030436. [PMID: 36767011 PMCID: PMC9914852 DOI: 10.3390/healthcare11030436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 01/21/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Literature on the prevention of medication errors is growing, highlighting that knowledge, attitude and behavior with regard to medication errors are strategic to planning of educational activities and evaluating their impact on professional practice. In this context, the present pilot study aims to translate and validate nursing professionals' knowledge, attitudes and behavior (KAB theory) concerning medication administration errors in ICU from English into Persian. Furthermore, two main objectives of the project were: performing a pilot study among Iranian nurses using the translated questionnaire and carrying out a cultural measurement of the KAB theory concerning medication administration errors in an ICU questionnaire across two groups of Italian and Iranian populations. METHODS A cross-cultural adaptation of an instrument, according to the Checklist for reporting of survey studies (CROSS), was performed. The convenience sample was made up of 529 Iranian and Italian registered nurses working in ICU. An exploratory factor analysis was performed and reliability was assessed. A multi-group confirmatory factor analysis was conducted to test the measurement invariance. Ethical approval was obtained. RESULTS There was an excellent internal consistency for the 19-item scale. Results regarding factorial invariance showed that the nursing population from Italy and Iran used the same cognitive framework to conceptualize the prevention of medication errors. CONCLUSIONS Findings from this preliminary translation and cross-cultural validation confirm that the questionnaire is a reliable and valid instrument within Persian healthcare settings. Moreover, these findings suggest that Italian and Persian nurses used an identical cognitive framework or mental model when thinking about medication errors prevention. The paper not only provides, for the first time, a validated instrument to evaluate the KAB theory in Iran, but it should promote other researchers in extending this kind of research, supporting those countries where attention to medical error is still increasing.
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Chu A, Kumar A, Depoorter G, Franklin BD, McLeod M. Learning from electronic prescribing errors: a mixed methods study of junior doctors' perceptions of training and individualised feedback data. BMJ Open 2022; 12:e056221. [PMID: 36549720 PMCID: PMC9772675 DOI: 10.1136/bmjopen-2021-056221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES To explore the views of junior doctors towards (1) electronic prescribing (EP) training and feedback, (2) readiness for receiving individualised feedback data about EP errors and (3) preferences for receiving and learning from EP feedback. DESIGN Explanatory sequential mixed methods study comprising quantitative survey (phase 1), followed by interviews and focus group discussions (phase 2). SETTING Three acute hospitals of a large English National Health Service organisation. PARTICIPANTS 25 of 89 foundation year 1 and 2 doctors completed the phase 1 survey; 5 participated in semi-structured interviews and 7 in a focus group in phase 2. RESULTS Foundation doctors in this mixed methods study reported that current feedback provision on EP errors was lacking or informal, and that existing EP training and resources were underused. They believed feedback about prescribing errors to be important and were keen to receive real-time, individualised EP feedback data. Feedback needed to be in manageable amounts, motivational and clearly signposting how to learn or improve. Participants wanted feedback and better training on the EP system to prevent repeating errors. In addition to individualised EP error data, they were positive about learning from general prescribing errors and aggregated EP data. However, there was a lack of consensus about how best to learn from statistical data. Potential limitations identified by participants included concern about how the data would be collected and whether it would be truly reflective of their performance. CONCLUSIONS Junior doctors would value feedback on their prescribing, and are keen to learn from EP errors, develop their clinical prescribing skills and use the EP interface effectively. We identified preferences for EP technology to enable provision of real-time data in combination with feedback to support learning and potentially reduce prescribing errors.
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Affiliation(s)
- Ann Chu
- Faculty Education Office, Imperial College London, London, UK
| | - Arika Kumar
- Department of Pharmacy, Imperial College Healthcare NHS Trust, London, UK
- UCL School of Pharmacy, London, UK
| | | | - Bryony Dean Franklin
- Department of Pharmacy, Imperial College Healthcare NHS Trust, London, UK
- UCL School of Pharmacy, London, UK
| | - Monsey McLeod
- Department of Pharmacy, Imperial College Healthcare NHS Trust, London, UK
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Berger V, Sommer C, Boje P, Hollmann J, Hummelt J, König C, Lezius S, van der Linde A, Marhenke C, Melzer S, Michalowski N, Baehr M, Langebrake C. The impact of pharmacists' interventions within the Closed Loop Medication Management process on medication safety: An analysis in a German university hospital. Front Pharmacol 2022; 13:1030406. [PMID: 36452222 PMCID: PMC9704051 DOI: 10.3389/fphar.2022.1030406] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 10/17/2022] [Indexed: 07/21/2023] Open
Abstract
Background: Single elements of the Closed Loop Medication Management process (CLMM), including electronic prescribing, involvement of clinical pharmacists (CPs), patient individual logistics and digital administration/documentation, have shown to improve medication safety and patient health outcomes. The impact of the complete CLMM on patient safety, as reflected in pharmacists' interventions (PIs), is largely unknown. Aim: To evaluate the extent and characterization of routine PIs performed by hospital-wide CPs at a university hospital with an implemented CLMM. Methods: This single-center study included all interventions documented by CPs on five self-chosen working days within 1 month using the validated online-database DokuPIK (Documentation of Pharmacists' Interventions in the Hospital). Based on different workflows, two groups of CPs were compared. One group operated as a part of the CLMM, the "Closed Loop Clinical Pharmacists" (CL-CPs), while the other group worked less dependent of the CLMM, the "Process Detached Clinical Pharmacists" (PD-CPs). The professional experience and the number of medication reviews were entered in an online survey. Combined pseudonymized datasets were analyzed descriptively after anonymization. Results: A total of 1,329 PIs were documented by nine CPs. Overall CPs intervened in every fifth medication review. The acceptance rate of PIs was 91.9%. The most common reasons were the categories "drugs" (e.g., indication, choice of formulation/drug and documentation/transcription) with 42.7%, followed by "dose" with 29.6%. One-quarter of PIs referred to the therapeutic subgroup "J01 antibacterials for systemic use." Of the 1,329 underlying PIs, 1,295 were classified as medication errors (MEs) and their vast majority (81.5%) was rated as "error, no harm" (NCC MERP categories B-D). Among PIs performed by CL-CPs (n = 1,125), the highest proportion of errors was categorized as B (56.5%), while in the group of PIs from PD-CPs (n = 170) errors categorized as C (68.2%) dominated (p < 0.001). Conclusion: Our study shows that a structured CLMM enables CPs to perform a high number of medication reviews while detecting and solving MEs at an early stage before they can cause harm to the patient. Based on key quality indicators for medication safety, the complete CLMM provides a suitable framework for the efficient medication management of inpatients.
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Affiliation(s)
- Vivien Berger
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Sommer
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peggy Boje
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Josef Hollmann
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julia Hummelt
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christina König
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Lezius
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Annika van der Linde
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Corinna Marhenke
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Simone Melzer
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nina Michalowski
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Baehr
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Claudia Langebrake
- Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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14
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Devin J, Cullinan S, Looi C, Cleary BJ. Identification of Prescribing Errors in an Electronic Health Record Using a Retract-and-Reorder Tool: A Pilot Study. J Patient Saf 2022; 18:e1076-e1082. [PMID: 35561350 DOI: 10.1097/pts.0000000000001011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aims of this study were to develop and to validate an adapted Retract-and-Reorder (RAR) tool to identify and quantify near-miss/intercepted prescribing errors in an electronic health record. METHODS This is a cross-sectional study between February and March 2021 in an Irish maternity hospital. We used the RAR tool to detect near-miss prescribing errors in audit log data. Potential errors flagged by the tool were validated using prescriber interviews. Chart reviews were performed if the prescriber was unavailable for interview. Errors were judged to be clinical decisions in chart reviews through review of narrative notes, order components, and patient's clinical history. Interviews were analyzed with reference to the London Protocol, a process of incident analysis that categorizes causes of errors into various contributory factors including patient factors, task and technology factors, and work environment. Logistic regression with robust clustered standard errors was used to determine predictors for near-miss prescribing errors. We calculated the positive predictive value of the RAR tool by dividing the number of confirmed near-miss prescribing errors by the total number of RAR events identified. RESULTS Eighty-four RAR events were identified in 27,407 medication orders. Seventy-one events were confirmed near-miss prescribing errors, resulting in a positive predictive value of 85.0% (95% confidence interval, 75%-91%) and an estimated near-miss prescribing error rate of 259/100,000 medication orders. Duplicate prescribing errors were most common (54/71, 76.1%). No errors were reported by prescribers. Consultants were less likely to make an error than nonconsultant hospital doctors (adjusted odds ratio, 0.10; 95% confidence interval, 0.01-0.84). Factors associated with errors included workload, staffing levels, and task structure. CONCLUSIONS Our adapted RAR tool identified a variety of near-miss prescribing errors not otherwise reported. The tool has been implemented in the study hospital as a patient safety resource. Further implementations are planned across Irish hospitals.
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Affiliation(s)
- Joan Devin
- From the RCSI School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin 2
| | - Shane Cullinan
- From the RCSI School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin 2
| | - Claudia Looi
- Department of Pharmacy, The Rotunda Hospital, Dublin 1, Ireland
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15
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Ahsan M. Improving steroid and immunosuppressant prescribing and treatment plans: quality improvement project on an intensive care unit. Future Healthc J 2022; 9:111-112. [PMID: 36311003 PMCID: PMC9601051 DOI: 10.7861/fhj.9-2-s111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Maheen Ahsan
- AImperial College Healthcare NHS Trust, London, UK
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16
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Kinlay M, Yi Zheng W, Burke R, Juraskova I, Ho LMR, Turton H, Trinh J, Baysari M. Stakeholder perspectives of system-related errors: Types, contributing factors, and consequences. Int J Med Inform 2022; 165:104821. [PMID: 35738163 DOI: 10.1016/j.ijmedinf.2022.104821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 06/02/2022] [Accepted: 06/09/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Despite growing evidence of the benefits of electronic medication management systems (EMMS), research has also identified a range of new safety risks linked with their use. There is limited qualitative research focusing on system-related errors that result from use of EMMS. The aim of this study was to explore in-depth stakeholders' perceptions and experiences of system-related errors. METHODS Semi-structured interviews were conducted with EMMS users and other relevant staff (e.g. supporting roles in EMMS) across a local health district in Sydney, Australia. Analysis was conducted iteratively using a general inductive approach, and then mapped to Reason's accident causation model, where codes were categorized as 1) unsafe acts (i.e. what error occurred), 2) latent conditions (i.e. what factors contributed to errors), and 3) consequences resulting from the error. RESULTS Twenty-five participants were interviewed between September 2020 and May 2021. Participants most frequently described omission errors (e.g. failure to check for duplicate orders) as unsafe acts, although commission errors and workarounds were also reported. Poor EMMS design was reported to be a significant workplace factor contributing to system-related errors, however participants also described user factors, such as an overreliance on the system, and organizational factors, such as system downtime, as contributing to errors. Reported consequences of system-related errors included medication errors, but also impacts to the EMMS and on workers. CONCLUSIONS EMMS design is a significant contributor to system-related errors, but this research showed that user and organizational factors are also at play. As these factors are not independent, minimizing system-related errors requires a multi-faceted approach, where mitigation strategies target not only the EMMS, but also the context in which the system has been implemented.
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Affiliation(s)
- Madaline Kinlay
- Biomedical Informatics and Digital Health, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
| | | | - Rosemary Burke
- Pharmacy Services, Sydney Local Health District, Sydney, Australia
| | - Ilona Juraskova
- School of Psychology, Faculty of Science, The University of Sydney, Sydney, Australia
| | | | - Hannah Turton
- Pharmacy Services, Sydney Local Health District, Sydney, Australia
| | - Jason Trinh
- Pharmacy Services, Sydney Local Health District, Sydney, Australia
| | - Melissa Baysari
- Biomedical Informatics and Digital Health, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Mariz Batista A, da Silva Gama ZA, Souza D. Validation of the QualiPresc instrument for assessing the quality of drug prescription writing in primary health care. PLoS One 2022; 17:e0267707. [PMID: 35544534 PMCID: PMC9094502 DOI: 10.1371/journal.pone.0267707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 04/13/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Adverse events related to drug prescriptions are the main patient safety issue in primary care; however there is a lack of validated instruments for assessing the quality of prescription writing, which covers the prescriber, the patient and the drug information. OBJECTIVE To develop and validate the QualiPresc instrument to assess and monitor the quality of drug prescriptions in primary care, accompanied by a self-instruction direction, with the goal of filling the gap in validated instruments to assess the quality of prescription writing. METHODOLOGY A validation study conducted in a municipality in Northeastern Brazil, based on prescriptions prepared in January 2021 by physicians assigned to 18 Basic Health Units and filed in 6 distribution/dispensing units. Four steps were covered: 1) Analysis of content validity of each indicator (relevance and adequacy); 2) Analysis of reliability via intra and inter-rater agreement of each indicator; 3) Analysis of the utility of each indicator; 4) Construction and analysis of the reliability of a weighted composite indicator based on effectiveness and safety scores for each indicator. RESULTS Twenty-nine potential indicators were listed, but only 13 were approved for validity, reliability and usefulness. Twelve indicators were excluded because of validity (<90% validity index) and four because they were not useful in the context of the study. Three weighted composite indicators were tested, but only one was approved for reliability and usefulness. The validated instrument therefore contains 13 indicators and 1 weighted composite indicator. CONCLUSION This study demonstrates the validity, reliability and usefulness of QualiPresc for the evaluation of prescription writing in the context of primary care. Application to contexts such as secondary care and tertiary care requires cross-cultural adaptation and new content validity. Educators, managers and health care professionals can access QualiPresc online, free of charge, to assess performance and provide feedback involving drug prescribers.
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Affiliation(s)
- Almária Mariz Batista
- Escola Multicampi de Ciências Médicas, Universidade Federal do Rio Grande do Norte, Caicó, Brazil
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal do Rio Grande do Norte, Natal, Brazil
| | | | - Dyego Souza
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal do Rio Grande do Norte, Natal, Brazil
- Departamento de Saúde Coletiva, Universidade Federal do Rio Grande do Norte, Natal, Brazil
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Impact of Computerized Provider Order Entry on Chemotherapy Medication Errors: A Systematic Review. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2022. [DOI: 10.5812/ijcm-120300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Context: Chemotherapy errors are considered the second most common cause of fatal medication errors (ME). Currently, computerized provider order entry (CPOE) is increasingly used to prevent or decrease ME and improve the safety of the medication process. Objectives: This study was conducted to systematically review the impacts of CPOE on the incidence of chemotherapy ME, the severity of errors, and adverse drug events (ADEs) in cancer care units. Data Sources: The literature search was conducted, using 5 databases of PubMed, EMBASE, Scopus, Web of Science, and ScienceDirect between 2000 and 2020. Search terms included keywords and MESH terms related to CPOE, ME, chemotherapy, and cancer care unit. Study Selection: Articles were included in this research if they investigated the CPOE system, reported ME, and were carried out in the oncology department. Non-English papers, duplications, review studies, and conference papers were excluded. Data Extraction: The selected papers were read repeatedly and related papers were extracted. All eligible articles were qualitatively evaluated with a tool provided by Downs. The extracted information included the author’s name, year of publication, study location, type of study, study objectives, and main findings. Results: A total of 829 studies were retrieved. Fourteen articles met the inclusion criteria. Ten studies (71%) reported the impact of CPOE on chemotherapy ME in comparison with the paper-based ordering method. In 4 studies (29%), researchers developed a CPOE for the oncology department, and the system was, then, assessed concerning user experience, safety challenges as well as the effects of CPOE on ME. Nine articles (64%) reported the impact of the CPOE system on ME only in the prescribing phase, and 5 studies (36%) examined ME in all phases of the chemotherapy process. Five studies (36%) reported the impact of the CPOE system on ADEs and the severity of errors. Conclusions: Implementing CPOE is associated with a significant reduction in ME in all phases of the chemotherapy process. However, the CPOE does not prevent all MEs and may cause new errors. The rigorous analysis of the chemotherapy process and considering the designing principles could help develop the CPOE systems and minimize ME.
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Giannetta N, Dionisi S, Tonello M, Di Simone E, Di Muzio M. A Worldwide Bibliometric Analysis of Published Literature on Medication Errors. J Patient Saf 2022; 18:201-209. [PMID: 35026796 DOI: 10.1097/pts.0000000000000894] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of the study was to map the recent literature on medication error to monitor the state of research and explore emerging research fronts. Specifically, the co-occurrences analysis aimed to research the conceptual structure of the medication errors, whereas the coauthorship analysis aimed to research the "authorities" that influenced the academic and political discussion on medication errors. METHODS The search for relevant studies was carried out through the Scopus. To map and monitor the state of research on medication error, a preliminary analysis was conducted through the year of publication, type of article, and language. The count of citation shows the most relevant work among those included. Bibliometric analyses were conducted, such as coauthorship analysis and co-occurrences analysis. RESULTS The search strategy yielded 5393 articles. Of these, 1267 articles were included. Four main themes emerged from this bibliometric analysis: (a) the exploration of human factors related to health care professionals that increase the risk of medication error, (b) the investigation of behaviors and strategies that can prevent the error in the preparation and administration stage, (c) the analysis of the benefits related to the presence of the pharmacist in hospital settings, and (d) the exploration of the consequences of a medication error and/or adverse effects of drugs. CONCLUSIONS For the first time, a bibliometric analysis of medication errors research in the world has been conducted and demonstrated that there is a wealth of contributions already being made that are well aligned to the World Health Organization challenge.
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Affiliation(s)
| | - Sara Dionisi
- From the Department of Biomedicine and Prevention, Tor Vergata University of Rome, Rome
| | - Monica Tonello
- Department of Biomedicine and Prevention, University of Rome Tor Vergata
| | - Emanuele Di Simone
- Nursing, Technical, Rehabilitation, Assistance and Research Department, IRCCS Istituti Fisioterapici Ospitalieri, IFO
| | - Marco Di Muzio
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
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20
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The impact of a novel medication scanner on administration errors in the hospital setting: a before and after feasibility study. BMC Med Inform Decis Mak 2022; 22:86. [PMID: 35351096 PMCID: PMC8962937 DOI: 10.1186/s12911-022-01828-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 03/16/2022] [Indexed: 11/29/2022] Open
Abstract
Objective The medication administration process is complex and consequently prone to errors. Closed Loop Medication Administration solutions aim to improve patient safety. We assessed the impact of a novel medication scanning device (MedEye) on the rate of medication administration errors in a large UK Hospital. Methods We performed a feasibility before and after study on one ward at a tertiary-care teaching hospital that used a commercial electronic prescribing and medication administration system. We conducted direct observations of nursing drug administration rounds before and after the MedEye implementation. We calculated the rate and type (‘timing’, ‘omission’ or ‘other’ error) of medication administration errors (MAEs) before and after the MedEye implementation. Results We observed a total of 1069 administrations before and 432 after the MedEye intervention was implemented. Data suggested that MedEye could support a reduction in MAEs. After adjusting for heterogeneity, we detected a decreasing effect of MedEye on overall errors (p = 0.0753). Non-timing errors (‘omission’ and ‘other’ errors) reduced from 51 (4.77%) to 11 (2.55%), a reduction of 46.5%, which had borderline significance at the 5% level, although this was lost after adjusting for confounders. Conclusions This pilot study detected a decreasing effect of MedEye on overall errors and a reduction in non-timing error rates that was clinically important as such errors are more likely to be associated with harm. Further research is needed to investigate the impact on a larger sample of medications. Supplementary Information The online version contains supplementary material available at 10.1186/s12911-022-01828-3.
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Jacobsohn GC, Leaf M, Liao F, Maru AP, Engstrom CJ, Salwei ME, Pankratz GT, Eastman A, Carayon P, Wiegmann DA, Galang JS, Smith MA, Shah MN, Patterson BW. Collaborative design and implementation of a clinical decision support system for automated fall-risk identification and referrals in emergency departments. HEALTHCARE (AMSTERDAM, NETHERLANDS) 2022; 10:100598. [PMID: 34923354 PMCID: PMC8881336 DOI: 10.1016/j.hjdsi.2021.100598] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 11/15/2021] [Accepted: 11/22/2021] [Indexed: 11/04/2022]
Abstract
Of the 3 million older adults seeking fall-related emergency care each year, nearly one-third visited the Emergency Department (ED) in the previous 6 months. ED providers have a great opportunity to refer patients for fall prevention services at these initial visits, but lack feasible tools for identifying those at highest-risk. Existing fall screening tools have been poorly adopted due to ED staff/provider burden and lack of workflow integration. To address this, we developed an automated clinical decision support (CDS) system for identifying and referring older adult ED patients at risk of future falls. We engaged an interdisciplinary design team (ED providers, health services researchers, information technology/predictive analytics professionals, and outpatient Falls Clinic staff) to collaboratively develop a system that successfully met user requirements and integrated seamlessly into existing ED workflows. Our rapid-cycle development and evaluation process employed a novel combination of human-centered design, implementation science, and patient experience strategies, facilitating simultaneous design of the CDS tool and intervention implementation strategies. This included defining system requirements, systematically identifying and resolving usability problems, assessing barriers and facilitators to implementation (e.g., data accessibility, lack of time, high patient volumes, appointment availability) from multiple vantage points, and refining protocols for communicating with referred patients at discharge. ED physician, nurse, and patient stakeholders were also engaged through online surveys and user testing. Successful CDS design and implementation required integration of multiple new technologies and processes into existing workflows, necessitating interdisciplinary collaboration from the onset. By using this iterative approach, we were able to design and implement an intervention meeting all project goals. Processes used in this Clinical-IT-Research partnership can be applied to other use cases involving automated risk-stratification, CDS development, and EHR-facilitated care coordination.
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Affiliation(s)
- Gwen Costa Jacobsohn
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA.
| | - Margaret Leaf
- Applied Data Science, Enterprise Analytics, UW Health, Madison, WI, USA.
| | - Frank Liao
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA; Applied Data Science, Enterprise Analytics, UW Health, Madison, WI, USA.
| | - Apoorva P. Maru
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Collin J. Engstrom
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA,Department of Computer Science, Winona State University, Rochester, MN, USA
| | - Megan E. Salwei
- Department of Industrial and Systems Engineering, University of Wisconsin, Madison, Wisconsin, USA,Center for Quality and Productivity Improvement, University of Wisconsin-Madison, Madison, Wisconsin, USA,Center for Research and Innovation in Systems Safety, Departments of Anesthesiology and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gerald T Pankratz
- Department of Medicine, Division of Geriatrics and Gerontology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Alexis Eastman
- Department of Medicine, Division of Geriatrics and Gerontology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Pascale Carayon
- Department of Industrial and Systems Engineering, University of Wisconsin, Madison, WI, USA; Center for Quality and Productivity Improvement, University of Wisconsin-Madison, Madison, WI, USA.
| | - Douglas A. Wiegmann
- Department of Industrial and Systems Engineering, University of Wisconsin, Madison, Wisconsin, USA,Center for Quality and Productivity Improvement, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Joel S. Galang
- Applied Data Science, Enterprise Analytics, UW Health, Madison, Wisconsin, USA
| | - Maureen A. Smith
- Health Innovation Program, University of Wisconsin-Madison, Madison, Wisconsin, USA,Department of Population Health Sciences, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Manish N. Shah
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA,Department of Medicine, Division of Geriatrics and Gerontology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA,Department of Population Health Sciences, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Brian W. Patterson
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA,Health Innovation Program, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Heed J, Klein S, Slee A, Watson N, Husband A, Slight S. An e-Delphi study to obtain expert consensus on the level of risk associated with preventable e-prescribing events. Br J Clin Pharmacol 2022; 88:3351-3359. [PMID: 35174527 PMCID: PMC9313843 DOI: 10.1111/bcp.15284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 12/10/2021] [Accepted: 01/26/2022] [Indexed: 11/30/2022] Open
Abstract
Aims We aim to seek expert opinion and gain consensus on the risks associated with a range of prescribing scenarios, preventable using e‐prescribing systems, to inform the development of a simulation tool to evaluate the risk and safety of e‐prescribing systems (ePRaSE). Methods We conducted a two‐round e‐Delphi survey where expert participants were asked to score pre‐designed prescribing scenarios using a five‐point Likert scale to ascertain the likelihood of occurrence of the prescribing event, likelihood of occurrence of harm and the severity of the harm. Results Twenty‐four experts consented to participate with 15 pand 13 participants completing rounds 1 and 2, respectively. Experts agreed on the level of risk associated with 136 out of 178 clinical scenarios with 131 scenarios categorised as high or extreme risk. Conclusion We identified 131 extreme or high‐risk prescribing scenarios that may be prevented using e‐prescribing clinical decision support. The prescribing scenarios represent a variety of categories, with drug–disease contraindications being the most frequent, representing 37 (27%) scenarios, and antimicrobial agents being the most common drug class, representing 28 (21%) of the scenarios. Our e‐Delphi study has achieved expert consensus on the risk associated with a range of clinical scenarios with most of the scenarios categorised as extreme or high risk. These prescribing scenarios represent the breadth of preventable prescribing error categories involving both basic and advanced clinical decision support. We will use the findings of this study to inform the development of the e‐prescribing risk and safety evaluation tool.
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Affiliation(s)
- Jude Heed
- School of Pharmacy Newcastle University Newcastle upon Tyne, UK
| | - Stephanie Klein
- Pharmacy Directorate, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Ann Slee
- Chief Clinical Information Officer (Medicines), NHS X, UK
| | - Neil Watson
- Pharmacy Directorate, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Andy Husband
- School of Pharmacy, Newcastle University, Newcastle upon Tyne, UK
| | - Sarah Slight
- School of Pharmacy, King George VI Building, Newcastle upon Tyne, UK
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23
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Kinlay M, Ho LMR, Zheng WY, Burke R, Juraskova I, Moles R, Baysari M. Electronic Medication Management Systems: Analysis of Enhancements to Reduce Errors and Improve Workflow. Appl Clin Inform 2021; 12:1049-1060. [PMID: 34758493 DOI: 10.1055/s-0041-1739196] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Electronic medication management (eMM) has been shown to reduce medication errors; however, new safety risks have also been introduced that are associated with system use. No research has specifically examined the changes made to eMM systems to mitigate these risks. OBJECTIVES To (1) identify system-related medication errors or workflow blocks that were the target of eMM system updates, including the types of medications involved, and (2) describe and classify the system enhancements made to target these risks. METHODS In this retrospective qualitative study, documents detailing updates made from November 2014 to December 2019 to an eMM system were reviewed. Medication-related updates were classified according to "rationale for changes" and "changes made to the system." RESULTS One hundred and seventeen updates, totaling 147 individual changes, were made to the eMM system over the 4-year period. The most frequent reasons for changes being made to the eMM were to prevent medication errors (24% of reasons), optimize workflow (22%), and support "work as done" on paper (16%). The most frequent changes made to the eMM were options added to lists (14% of all changes), extra information made available on the screen (8%), and the wording or phrasing of text modified (8%). Approximately a third of the updates (37%) related to high-risk medications. The reasons for system changes appeared to vary over time, as eMM functionality and use expanded. CONCLUSION To our knowledge, this is the first study to systematically review and categorize system updates made to overcome new safety risks associated with eMM use. Optimization of eMM is an ongoing process, which changes over time as users become more familiar with the system and use is expanded to more sites. Continuous monitoring of the system is necessary to detect areas for improvement and capitalize on the benefits an electronic system can provide.
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Affiliation(s)
- Madaline Kinlay
- Biomedical Informatics and Digital Health, School of Medical Sciences, Charles Perkins Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | | | | | - Rosemary Burke
- Pharmacy Services, Sydney Local Health District, Sydney, Australia
| | - Ilona Juraskova
- School of Psychology, Faculty of Science, The University of Sydney, Sydney, Australia
| | - Rebekah Moles
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Melissa Baysari
- Biomedical Informatics and Digital Health, School of Medical Sciences, Charles Perkins Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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24
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Videau M, Charpiat B, Vermorel C, Bosson JL, Conort O, Bedouch P. Characteristics of pharmacist's interventions triggered by prescribing errors related to computerised physician order entry in French hospitals: a cross-sectional observational study. BMJ Open 2021; 11:e045778. [PMID: 34635512 PMCID: PMC8506887 DOI: 10.1136/bmjopen-2020-045778] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Manon Videau
- Pharmacy, Grenoble Alpes University Hospital, Grenoble, France
- CNRS/TIMC-IMAG UMR5525/ThEMAS, F-38041, Université Grenoble Alpes, Grenoble, France
| | - Bruno Charpiat
- CNRS/TIMC-IMAG UMR5525/ThEMAS, F-38041, Université Grenoble Alpes, Grenoble, France
- Pharmacy, Hopital de la Croix-Rousse, Hospices civils de Lyon, Lyon, France
| | - Céline Vermorel
- CNRS/TIMC-IMAG UMR5525/ThEMAS, F-38041, Université Grenoble Alpes, Grenoble, France
| | - Jean-Luc Bosson
- CNRS/TIMC-IMAG UMR5525/ThEMAS, F-38041, Université Grenoble Alpes, Grenoble, France
| | - Ornella Conort
- Pharmacy, Hopital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Pierrick Bedouch
- Pharmacy, Grenoble Alpes University Hospital, Grenoble, France
- CNRS/TIMC-IMAG UMR5525/ThEMAS, F-38041, Université Grenoble Alpes, Grenoble, France
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25
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Jungreithmayr V, Meid AD, Haefeli WE, Seidling HM. The impact of a computerized physician order entry system implementation on 20 different criteria of medication documentation-a before-and-after study. BMC Med Inform Decis Mak 2021; 21:279. [PMID: 34635100 PMCID: PMC8504043 DOI: 10.1186/s12911-021-01607-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 08/09/2021] [Indexed: 11/25/2022] Open
Abstract
Background The medication process is complex and error-prone. To avoid medication errors, a medication order should fulfil certain criteria, such as good readability and comprehensiveness. In this context, a computerized physician order entry (CPOE) system can be helpful. This study aims to investigate the distinct effects on the quality of prescription documentation of a CPOE system implemented on general wards in a large tertiary care hospital. Methods In a retrospective analysis, the prescriptions of two groups of 160 patients each were evaluated, with data collected before and after the introduction of a CPOE system. According to nationally available recommendations on prescription documentation, it was assessed whether each prescription fulfilled the established 20 criteria for a safe, complete, and actionable prescription. The resulting fulfilment scores (prescription-Fscores) were compared between the pre-implementation and the post-implementation group and a multivariable analysis was performed to identify the effects of further covariates, i.e., the prescription category, the ward, and the number of concurrently prescribed drugs. Additionally, the fulfilment of the 20 criteria was assessed at an individual criterion-level (denoted criteria-Fscores). Results The overall mean prescription-Fscore increased from 57.4% ± 12.0% (n = 1850 prescriptions) before to 89.8% ± 7.2% (n = 1592 prescriptions) after the implementation (p < 0.001). At the level of individual criteria, criteria-Fscores significantly improved in most criteria (n = 14), with 6 criteria reaching a total score of 100% after CPOE implementation. Four criteria showed no statistically significant difference and in two criteria, criteria-Fscores deteriorated significantly. A multivariable analysis confirmed the large impact of the CPOE implementation on prescription-Fscores which was consistent when adjusting for the confounding potential of further covariates. Conclusions While the quality of prescription documentation generally increases with implementation of a CPOE system, certain criteria are difficult to fulfil even with the help of a CPOE system. This highlights the need to accompany a CPOE implementation with a thorough evaluation that can provide important information on possible improvements of the software, training needs of prescribers, or the necessity of modifying the underlying clinical processes. Supplementary Information The online version contains supplementary material available at 10.1186/s12911-021-01607-6.
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Affiliation(s)
- Viktoria Jungreithmayr
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,Cooperation Unit Clinical Pharmacy, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | | | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.,Cooperation Unit Clinical Pharmacy, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Hanna M Seidling
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany. .,Cooperation Unit Clinical Pharmacy, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
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26
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Power A, Stewart D, Craig G, Boyter A, Reid F, Stewart F, Cunningham S, Maxwell S. Student and pre-registration pharmacist performance in a UK Prescribing Assessment. Int J Clin Pharm 2021; 44:100-109. [PMID: 34495454 DOI: 10.1007/s11096-021-01317-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 08/11/2021] [Indexed: 11/28/2022]
Abstract
Student and pre-registration pharmacist performance in a UK Prescribing Assessment': room for improvement and need for curricular change Background Increasingly the global policy direction is for patient-facing pharmacist prescribers. The 'UK Prescribing Safety Assessment' (PSA) was developed for medical graduates to demonstrate prescribing competencies in relation to the safe and effective use of medicines. Objectives To determine PSA performance of final year undergraduate student pharmacists (year 4) and pre-registration pharmacy graduates (year 5) and explore their opinions on its suitability. Setting Scotland, UK Methods Final year undergraduates (n = 238) and pre-registration pharmacists (n = 167) were briefed and undertook the PSA. PSA questions were mapped to specific thematic areas with 30 questions over 60 min. Data was analysed using descriptive statistics. A questionnaire was completed to gauge opinions on appropriateness of the PSA. Main Outcome Measure PSA scores Results Mean total PSA score for pre-registration pharmacists (64.4, SD 10) was significantly higher than for undergraduates (51.2, SD 12.0,) (p < 0.001). Pre-registration pharmacists performed significantly better across all question areas (all p < 0.001 other than 'adverse drug reactions', p < 0.01). Hospital pre-registration pharmacists performed statistically significantly better than community with higher overall scores (67.4, SD 9.8 v 63.2, SD 9.8, p < 0.05). Positive views on the appropriateness of the approach and the usability of the online interface were obtained from participants. Conclusion Hospital pre-registration pharmacists performed better than the undergraduates, but there is a need to improve prescribing skills in all, most notably in diagnostic skills. The PSA is acceptable to the participants. These results will help inform pharmacy curricula development and provides a cross-disciplinary method of assessment of prescribing competence.
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Affiliation(s)
- Ailsa Power
- Pharmacy NHS Education for Scotland, 2 Central Quay, Glasgow, G38BW, Scotland.
| | - Derek Stewart
- College of Pharmacy, QU Health, Qatar University, PO Box 2713, Doha, Qatar
| | - Gail Craig
- Pharmacy NHS Education for Scotland, 2 Central Quay, Glasgow, G38BW, Scotland
| | - Anne Boyter
- Strathclyde Institute of Pharmacy & Biomedical Sciences, University of Strathclyde, 161 Cathedral St, Glasgow, G4 0RE, Scotland
| | - Fiona Reid
- Retired, Formerly of NHS Education for Scotland, 2 Central Quay, Glasgow, G38BW, Scotland
| | - Fiona Stewart
- Pharmacy NHS Education for Scotland, 2 Central Quay, Glasgow, G38BW, Scotland
| | - Scott Cunningham
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, AB10 7GJ, Scotland
| | - Simon Maxwell
- Clinical Pharmacology Unit, Edinburgh Medical School, Medical Education Centre, Western General Hospital, Edinburgh, EH14 2XU, Scotland
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27
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Romanelli RJ, Schwartz NRM, Dixon WG, Rodriguez-Watson C, Sauer BC, Albright D, Marcum ZA. The use of narrative electronic prescribing instructions in pharmacoepidemiology: A scoping review for the International Society for Pharmacoepidemiology. Pharmacoepidemiol Drug Saf 2021; 30:1281-1292. [PMID: 34278660 PMCID: PMC8419095 DOI: 10.1002/pds.5331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 07/10/2021] [Accepted: 07/12/2021] [Indexed: 11/22/2022]
Abstract
Narrative electronic prescribing instructions (NEPIs) are text that convey information on the administration or co‐administration of a drug as directed by a prescriber. For researchers, NEPIs have the potential to advance our understanding of the risks and benefits of medications in populations; however, due to their unstructured nature, they are not often utilized. The goal of this scoping review was to evaluate how NEPIs are currently employed in research, identify opportunities and challenges for their broader application, and provide recommendations on their future use. The scoping review comprised a comprehensive literature review and a survey of key stakeholders. From the literature review, we identified 33 primary articles that described the use of NEPIs. The majority of articles (n = 19) identified issues with the quality of information in NEPIs compared with structured prescribing information; nine articles described the development of novel algorithms that performed well in extracting information from NEPIs, and five described the used of manual or simpler algorithms to extract prescribing information from NEPIs. A survey of 19 stakeholders indicated concerns for the quality of information in NEPIs and called for standardization of NEPIs to reduce data variability/errors. Nevertheless, stakeholders believed NEPIs present an opportunity to identify prescriber's intent for the prescription and to study temporal treatment patterns. In summary, NEPIs hold much promise for advancing the field of pharmacoepidemiology. Researchers should take advantage of addressing important questions that can be uniquely answered with NEPIs, but exercise caution when using this information and carefully consider the quality of the data.
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Affiliation(s)
- Robert J Romanelli
- Center for Health Systems Research, Sutter Health, Walnut Creek, California, USA
| | - Naomi R M Schwartz
- The Comparative Health Outcomes Policy and Economics Institute, School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - William G Dixon
- Center for Epidemiology Versus Arthritis, University of Manchester, Manchester, UK
| | - Carla Rodriguez-Watson
- Innovation in Medical Evidence Development and Surveillance (IMEDS), Reagan-Udall Foundation for the Food and Drug Administration, Washington, DC, USA
| | - Brian C Sauer
- Division of Epidemiology, University of Utah, Salt Lake City, Utah, USA
| | | | - Zachary A Marcum
- The Comparative Health Outcomes Policy and Economics Institute, School of Pharmacy, University of Washington, Seattle, Washington, USA
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28
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Cabri A, Barsegyan N, Postelnick M, Schulz L, Nguyen V, Szwak J, Shane R. Pharmacist intervention on prescribing errors: Use of a standardized approach in the inpatient setting. Am J Health Syst Pharm 2021; 78:2151-2158. [PMID: 34283219 PMCID: PMC8406888 DOI: 10.1093/ajhp/zxab278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Purpose The objective of this study was to implement a standardized process across health systems to determine the prevalence and clinical relevance of prescribing errors intercepted by pharmacists. Methods This prospective, multicenter, observational study was conducted across 11 hospitals. Pharmacist-intercepted prescribing errors were collected during inpatient order verification over 6 consecutive weeks utilizing a standardized documentation process. The potential harm of each error was evaluated using a modified National Coordinating Council for Medication Error Reporting and Prevention (NCC-MERP) index with physician validation, and errors were stratified into those with potentially low, serious, or life-threatening harm. Endpoints included the median error rate per 1,000 patient days, error type, and potential harm with correlating cost avoidance. Results Pharmacists intervened on 7,187 errors, resulting in a mean error rate of 39 errors per 1,000 patient days. Among the errors, 46.6% (n = 3,349) were determined to have potentially serious consequences and 2.4% (n = 175) could have been life-threatening if not intercepted. This equates to $874,000 in avoided cost. The top 3 error types occurring with the highest frequency were “wrong dose/rate/frequency” (n = 2,298, 32.0%), “duplicate therapy” (n = 1,431, 19.9%), and “wrong timing” (n = 960, 13.4%). “Wrong dose/rate/frequency” (n = 49, 28%), “duplicate therapy” (n = 26, 14.9%), and “drug-disease interaction” (n = 24, 13.7%) errors occurred with the highest frequency among errors with potential for life-threatening harm. “Wrong dose/rate/frequency” (n = 1,028, 30.7%), “wrong timing” (n = 573, 17.1%), and “duplicate therapy” (n = 482, 14.4%) errors occurred with the highest frequency among errors with potentially serious harm. Conclusion Documentation of pharmacist intervention on prescribing errors via a standardized process creates a platform for multicenter analysis of prescribing error trends and an opportunity for development of system-wide solutions to reduce potential harm from prescribing errors.
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Affiliation(s)
- Ann Cabri
- Department of Pharmacy Services, University of California Davis Health, Sacramento, CA, USA
| | - Naira Barsegyan
- Department of Pharmacy Services, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michael Postelnick
- Department of Pharmacy Services, Northwestern Medicine, Chicago, IL, USA
| | - Lucas Schulz
- Department of Pharmacy Services, University of Wisconsin Health, Madison, WI, USA
| | - Victoria Nguyen
- Department of Pharmacy Services, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jennifer Szwak
- Department of Pharmacy Services, University of Chicago Medicine, Chicago, IL, USA
| | - Rita Shane
- Department of Pharmacy Services, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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29
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Zheng WY, Van Dort B, Marcilly R, Day R, Burke R, Shakib S, Ku Y, Reid-Anderson H, Baysari M. A Tool for Evaluating Medication Alerting Systems: Development and Initial Assessment. JMIR Med Inform 2021; 9:e24022. [PMID: 34269680 PMCID: PMC8325080 DOI: 10.2196/24022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/04/2020] [Accepted: 06/03/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND It is well known that recommendations from electronic medication alerts are seldom accepted or acted on by users. Key factors affecting the effectiveness of medication alerts include system usability and alert design. Thus, human factors principles that apply knowledge of human capabilities and limitations are increasingly used in the design of health technology to improve the usability of systems. OBJECTIVE This study aims to evaluate a newly developed evidence-based self-assessment tool that allows the valid and reliable evaluation of computerized medication alerting systems. This tool was developed to be used by hospital staff with detailed knowledge of their hospital's computerized provider order entry system and alerts to identify and address potential system deficiencies. In this initial assessment, we aim to determine whether the items in the tool can measure compliance of medication alerting systems with human factors principles of design, the tool can be consistently used by multiple users to assess the same system, and the items are easy to understand and perceived to be useful for assessing medication alerting systems. METHODS The Tool for Evaluating Medication Alerting Systems (TEMAS) was developed based on human factors design principles and consisted of 66 items. In total, 18 staff members recruited across 6 hospitals used the TEMAS to assess their medication alerting systems. Data collected from participant assessments were used to evaluate the validity, reliability, and usability of the TEMAS. Validity was assessed by comparing the results of the TEMAS with those of prior in-house evaluations. Reliability was measured using Krippendorff α to determine agreement among assessors. A 7-item survey was used to determine usability. RESULTS The participants reported mostly negative (n=8) and neutral (n=7) perceptions of alerts in their medication alerting system. However, the validity of the TEMAS could not be directly tested, as participants were unaware of any results from prior in-house evaluations. The reliability of the TEMAS, as measured by Krippendorff α, was low to moderate (range 0.26-0.46); however, participant feedback suggests that individuals' knowledge of the system varied according to their professional background. In terms of usability, 61% (11/18) of participants reported that the TEMAS items were generally easy to understand; however, participants suggested the revision of 22 items to improve clarity. CONCLUSIONS This initial assessment of the TEMAS allowed the identification of its components that required modification to improve usability and usefulness. It also revealed that for the TEMAS to be effective in facilitating a comprehensive assessment of a medication alerting system, it should be completed by a multidisciplinary team of hospital staff from both clinical and technical backgrounds to maximize their knowledge of systems.
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Affiliation(s)
- Wu Yi Zheng
- Black Dog Institute, Randwick, NSW, Australia.,The University of Sydney, Faculty of Medicine and Health, School of Medical Sciences, Biomedical Informatics and Digital Health, Sydney, Australia
| | - Bethany Van Dort
- The University of Sydney, Faculty of Medicine and Health, School of Medical Sciences, Biomedical Informatics and Digital Health, Sydney, Australia
| | - Romaric Marcilly
- Univ Lille, CHU Lille, ULR 2694, METRICS: Évaluation des Technologies de santé des Pratiques médicales, Lille, France.,INSERM, CHU Lille, CIC-IT/Evalab 1403, Centre d'Investigation Clinique, Lille, France
| | - Richard Day
- University of New South Wales, Randwick, Australia
| | | | | | - Young Ku
- Hunter New England Local Health District, Newcastle, Australia
| | | | - Melissa Baysari
- The University of Sydney, Faculty of Medicine and Health, School of Medical Sciences, Biomedical Informatics and Digital Health, Sydney, Australia
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30
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Shin GW, Lee Y, Park T, Cho I, Yun MH, Bahn S, Lee JH. Investigation of usability problems of electronic medical record systems in the emergency department. Work 2021; 72:221-238. [PMID: 34120924 DOI: 10.3233/wor-205262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Despite the benefits of using electronic medical record (EMR) systems, existing studies show that many healthcare providers are uncertain regarding their usability. The usability issues of these systems decrease their efficiency, discourage clinicians, and cause dissatisfaction among patients, which may result in safety risks and harm. OBJECTIVE The aim of this study was to collect and analyze EMR system usability problems from actual users. Practical user interface guidelines were presented based on the medical practices of these users. METHODS Employing an online questionnaire with a seven-point Likert scale, usability issues of EMR systems were collected from 200 emergency department healthcare providers (103 physicians (medical doctors) and 97 nurses) from South Korea. RESULTS The most common usability problem among the physicians and nurses was generating in-patient selection. This pertained to the difficulty in finding the required information on-screen because of poor visibility and a lack of distinctiveness. CONCLUSIONS The major problems of EMR systems and their causes were identified. It is recommended that intensive visual enhancement of EMR system interfaces should be implemented to support user tasks. By providing a better understanding of the current usability problems among medical practitioners, the results of this study can be useful for developing EMR systems with increased effectiveness and efficiency.
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Affiliation(s)
- Gee Won Shin
- Department of Industrial Engineering, Seoul National University, Seoul
| | - Yura Lee
- Department of Information Medicine, Asan Medical Center, Seoul
| | - Taezoon Park
- Department of Industrial & Information Systems Engineering, Soongsil University, Seoul
| | - Insook Cho
- Nursing Department, Inha University, Incheon
| | - Myung Hwan Yun
- Department of Industrial Engineering, Seoul National University, Seoul
| | - Sangwoo Bahn
- Department of Industrial and Management Systems Engineering, Kyung Hee University, Yongin
| | - Jae-Ho Lee
- Department of Information Medicine, Asan Medical Center, Seoul.,Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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31
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Abraham J, Galanter WL, Touchette D, Xia Y, Holzer KJ, Leung V, Kannampallil T. Risk factors associated with medication ordering errors. J Am Med Inform Assoc 2021; 28:86-94. [PMID: 33221852 DOI: 10.1093/jamia/ocaa264] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 09/30/2020] [Accepted: 10/06/2020] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE We utilized a computerized order entry system-integrated function referred to as "void" to identify erroneous orders (ie, a "void" order). Using voided orders, we aimed to (1) identify the nature and characteristics of medication ordering errors, (2) investigate the risk factors associated with medication ordering errors, and (3) explore potential strategies to mitigate these risk factors. MATERIALS AND METHODS We collected data on voided orders using clinician interviews and surveys within 24 hours of the voided order and using chart reviews. Interviews were informed by the human factors-based SEIPS (Systems Engineering Initiative for Patient Safety) model to characterize the work systems-based risk factors contributing to ordering errors; chart reviews were used to establish whether a voided order was a true medication ordering error and ascertain its impact on patient safety. RESULTS During the 16-month study period (August 25, 2017, to December 31, 2018), 1074 medication orders were voided; 842 voided orders were true medication errors (positive predictive value = 78.3 ± 1.2%). A total of 22% (n = 190) of the medication ordering errors reached the patient, with at least a single administration, without causing patient harm. Interviews were conducted on 355 voided orders (33% response). Errors were not uniquely associated with a single risk factor, but the causal contributors of medication ordering errors were multifactorial, arising from a combination of technological-, cognitive-, environmental-, social-, and organizational-level factors. CONCLUSIONS The void function offers a practical, standardized method to create a rich database of medication ordering errors. We highlight implications for utilizing the void function for future research, practice and learning opportunities.
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Affiliation(s)
- Joanna Abraham
- Department of Anesthesiology, Washington University School of Medicine in St. Louis,St. Louis, Missouri, USA.,Institute for Informatics, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - William L Galanter
- Department of Medicine, College of Medicine, University of Illinois at Chicago,Chicago, Illinois, USA.,Department of Pharmacy Systems, Outcome and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Daniel Touchette
- Department of Pharmacy Systems, Outcome and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Yinglin Xia
- Department of Medicine, College of Medicine, University of Illinois at Chicago,Chicago, Illinois, USA
| | - Katherine J Holzer
- Department of Anesthesiology, Washington University School of Medicine in St. Louis,St. Louis, Missouri, USA
| | - Vania Leung
- Department of Medicine, College of Medicine, University of Illinois at Chicago,Chicago, Illinois, USA
| | - Thomas Kannampallil
- Department of Anesthesiology, Washington University School of Medicine in St. Louis,St. Louis, Missouri, USA.,Institute for Informatics, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
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Soares N, Singhal S, Kloosterman C, Bailey T. An Interdisciplinary Approach to Reducing Errors in Extracted Electronic Health Record Data for Research. PERSPECTIVES IN HEALTH INFORMATION MANAGEMENT 2021; 18:1f. [PMID: 34035787 PMCID: PMC8120677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Erroneous electronic health record (EHR) data capture is a barrier to preserving data integrity. We assessed the impact of an interdisciplinary process in minimizing EHR data loss from prescription orders. We implemented a three-step approach to reduce data loss due to missing medication doses: Step 1-A data analyst updated the request code to optimize data capture; Step 2-A pharmacist and physician identified variations in EHR prescription workflows; and Step 3-The clinician team determined daily doses for patients with multiple prescriptions in the same encounter. The initial report contained 1421 prescriptions, with 377 (26.5 percent) missing dosages. Missing dosages reduced to 361 (26.3 percent) prescriptions following Step 1, and twenty-three (1.7 percent) records after Step 2. After Step 3, 1210 prescriptions remained, including 16 (1.3 percent) prescriptions missing doses. Prescription data is susceptible to missing values due to multiple data capture workflows. Our approach minimized data loss, improving its validity in retrospective research.
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A Longitudinal Assessment of the Quality of Insulin Prescribing with Different Prescribing Systems. PHARMACY 2021; 9:pharmacy9010053. [PMID: 33807829 PMCID: PMC8005941 DOI: 10.3390/pharmacy9010053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 02/05/2021] [Accepted: 02/27/2021] [Indexed: 11/17/2022] Open
Abstract
Accurate and complete prescriptions of insulin are crucial to prevent medication errors from occurring. Two core components for safe insulin prescriptions are the word 'units' being written in full for the dose, and clear documentation of the insulin device alongside the name. A retrospective review of annual audit data was conducted for insulin prescriptions to assess the impact of changes to the prescribing system within a secondary care setting, at five time points over a period of 7 years (2014 to 2020). The review points were based on when changes were made, from standardized paper charts with a dedicated section for insulin prescribing, to a standalone hospital wide electronic prescribing and medicines administration (ePMA) system, and finally an integrated electronic health record system (EHRS). The measured outcomes were compliance with recommended standards for documentation of 'units' in full, and inclusion of the insulin device as part of the prescription. Overall, an improvement was seen in both outcomes of interest. Device documentation improved incrementally with each system change-34% for paper charts, 23%-56% for standalone ePMA, and 100% for ePMA integrated within EHRS. Findings highlight that differences in ePMA systems may have varying impact on safe prescribing practices.
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Shahmoradi L, Safdari R, Ahmadi H, Zahmatkeshan M. Clinical decision support systems-based interventions to improve medication outcomes: A systematic literature review on features and effects. Med J Islam Repub Iran 2021; 35:27. [PMID: 34169039 PMCID: PMC8214039 DOI: 10.47176/mjiri.35.27] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Indexed: 01/24/2023] Open
Abstract
Background: Clinical decision support systems (CDSSs) interventions were used to improve the life quality and safety in patients and also to improve practitioner performance, especially in the field of medication. Therefore, the aim of the paper was to summarize the available evidence on the impact, outcomes and significant factors on the implementation of CDSS in the field of medicine. Methods: This study is a systematic literature review. PubMed, Cochrane Library, Web of Science, Scopus, EMBASE, and ProQuest were investigated by 15 February 2017. The inclusion requirements were met by 98 papers, from which 13 had described important factors in the implementation of CDSS, and 86 were medicated-related. We categorized the system in terms of its correlation with medication in which a system was implemented, and our intended results were examined. In this study, the process outcomes (such as; prescription, drug-drug interaction, drug adherence, etc.), patient outcomes, and significant factors affecting the implementation of CDSS were reviewed. Results: We found evidence that the use of medication-related CDSS improves clinical outcomes. Also, significant results were obtained regarding the reduction of prescription errors, and the improvement in quality and safety of medication prescribed. Conclusion: The results of this study show that, although computer systems such as CDSS may cause errors, in most cases, it has helped to improve prescribing, reduce side effects and drug interactions, and improve patient safety. Although these systems have improved the performance of practitioners and processes, there has not been much research on the impact of these systems on patient outcomes.
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Affiliation(s)
- Leila Shahmoradi
- Health Information Management Department, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Safdari
- Health Information Management Department, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Ahmadi
- OIM Department, Aston Business School, Aston University, Birmingham B4 7ET, United Kingdom
| | - Maryam Zahmatkeshan
- Noncommunicable Diseases Research Center, School of Medicine, Fasa University of Medical Sciences, Fasa, Iran
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Carlson A, Nelson ME, Patel H. Longitudinal impact of a pre-populated default quantity on emergency department opioid prescriptions. J Am Coll Emerg Physicians Open 2021; 2:e12337. [PMID: 33521788 PMCID: PMC7819264 DOI: 10.1002/emp2.12337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/13/2020] [Accepted: 11/24/2020] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Previously published studies indicate that a pre-populated default quantity may decrease opioid amounts on discharge prescriptions from the emergency department (ED). However, the longitudinal effect of defaulted quantities has not been described in the literature. METHODS A retrospective review of electronic health record data from visits to 4 hospital EDs in a community health system examined opioid prescription dispense quantities 3.5 years pre- and 6.5 years post-implementation of a defaulted dispense quantity of seventeen. The primary purpose was to determine the percentage of ED discharge opioid prescriptions containing the prepopulated default dispense quantity after implementation. The longitudinal effect of a default quantity implementation on the average quantity prescribed (normalized per 1000 visits) was examined by comparing the pre-implementation period (January 1, 2009-July 31, 2012) to the post-implementation period (August 1, 2012-June 30, 2018). RESULTS After implementation in 2012, the acceptance rate of the default dispense quantity increased each year, up to 48% in 2016 and maintained through 2018. A significant decrease in prescribed opioid quantities post-default quantity implementation was sustained, with the average quantity prescribed from 2015-2018 maintained at 17 or lower. CONCLUSION A pre-populated default quantity impacts discharge opioid prescribing as evidenced by a high sustained rate of prescriber utilization over years and reduction in the per prescription average pill quantity. The acceptance of a pre-populated default quantity may allow for selection of even a lower quantity to influence prescribing patterns of opioid analgesics.
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Affiliation(s)
| | - Michael E. Nelson
- NorthShore University Health SystemEvanstonILUSA
- John H. Stroger Jr. Hospital of Cook CountyCook County HealthChicagoILUSA
| | - Hina Patel
- NorthShore University Health SystemEvanstonILUSA
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Hussain MI, Reynolds TL, Zheng K. Medication safety alert fatigue may be reduced via interaction design and clinical role tailoring: a systematic review. J Am Med Inform Assoc 2021; 26:1141-1149. [PMID: 31206159 DOI: 10.1093/jamia/ocz095] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/14/2019] [Accepted: 05/19/2019] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Alert fatigue limits the effectiveness of medication safety alerts, a type of computerized clinical decision support (CDS). Researchers have suggested alternative interactive designs, as well as tailoring alerts to clinical roles. As examples, alerts may be tiered to convey risk, and certain alerts may be sent to pharmacists. We aimed to evaluate which variants elicit less alert fatigue. MATERIALS AND METHODS We searched for articles published between 2007 and 2017 using the PubMed, Embase, CINAHL, and Cochrane databases. We included articles documenting peer-reviewed empirical research that described the interactive design of a CDS system, to which clinical role it was presented, and how often prescribers accepted the resultant advice. Next, we compared the acceptance rates of conventional CDS-presenting prescribers with interruptive modal dialogs (ie, "pop-ups")-with alternative designs, such as role-tailored alerts. RESULTS Of 1011 articles returned by the search, we included 39. We found different methods for measuring acceptance rates; these produced incomparable results. The most common type of CDS-in which modals interrupted prescribers-was accepted the least often. Tiering by risk, providing shortcuts for common corrections, requiring a reason to override, and tailoring CDS to match the roles of pharmacists and prescribers were the most common alternatives. Only 1 alternative appeared to increase prescriber acceptance: role tailoring. Possible reasons include the importance of etiquette in delivering advice, the cognitive benefits of delegation, and the difficulties of computing "relevance." CONCLUSIONS Alert fatigue may be mitigated by redesigning the interactive behavior of CDS and tailoring CDS to clinical roles. Further research is needed to develop alternative designs, and to standardize measurement methods to enable meta-analyses.
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Affiliation(s)
- Mustafa I Hussain
- Department of Informatics, University of California, Irvine, Irvine, California, USA
| | - Tera L Reynolds
- Department of Informatics, University of California, Irvine, Irvine, California, USA
| | - Kai Zheng
- Department of Informatics, University of California, Irvine, Irvine, California, USA
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Kinlay M, Zheng WY, Burke R, Juraskova I, Moles R, Baysari M. Medication errors related to computerized provider order entry systems in hospitals and how they change over time: A narrative review. Res Social Adm Pharm 2020; 17:1546-1552. [PMID: 33353834 DOI: 10.1016/j.sapharm.2020.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/08/2020] [Accepted: 12/13/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Evaluations of computerized provider order entry (CPOE) systems have revealed that reductions in certain types of medication errors occur simultaneously with the emergence of system-related errors - errors that are unlikely or not possible to occur with the use of paper-based medication charts. System-related errors appear to persist many years post-implementation of CPOE, although little is known about whether the types and rates of system-related errors that occur immediately following CPOE implementation are similar to those that endure or emerge after years of system use. OBJECTIVE To analyze and synthesize the literature on system-related errors, specifically in relation to the length of time that CPOE systems have been in use, to determine what is currently known about how system-related errors change over time. METHODS A literature search was undertaken using the PubMed database to identify English language articles published between January 2005 and March 2020 that provided original data on system-related errors resulting from CPOE system use. Studies were included if they provided results on system-related errors and information relating to the length of time that CPOE had been in use. RESULTS Thirty-one studies met the inclusion criteria for this narrative review. System-related errors were identified and described during short, medium and long-term use of CPOE systems, but no single study examined how errors changed over time. In comparing findings across studies, results suggest that system-related errors persist with long-term use of CPOE systems, although likely to occur at a reduced rate. CONCLUSIONS This review has highlighted a significant gap in knowledge on how system-related errors change over time. Determining what and when system-related errors occur and the system factors that contribute to their occurrence at different time points after CPOE implementation is necessary for the future prevention and mitigation of these errors.
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Affiliation(s)
- Madaline Kinlay
- Discipline of Biomedical Informatics and Digital Health, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
| | - Wu Yi Zheng
- Discipline of Biomedical Informatics and Digital Health, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Black Dog Institute, Sydney, Australia
| | - Rosemary Burke
- Pharmacy Services, Sydney Local Health District, Sydney, Australia
| | - Ilona Juraskova
- School of Psychology, Faculty of Science, The University of Sydney, Sydney, Australia
| | - Rebekah Moles
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Melissa Baysari
- Discipline of Biomedical Informatics and Digital Health, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Devin J, Cleary BJ, Cullinan S. The impact of health information technology on prescribing errors in hospitals: a systematic review and behaviour change technique analysis. Syst Rev 2020; 9:275. [PMID: 33272315 PMCID: PMC7716445 DOI: 10.1186/s13643-020-01510-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 10/26/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Health information technology (HIT) is known to reduce prescribing errors but may also cause new types of technology-generated errors (TGE) related to data entry, duplicate prescribing, and prescriber alert fatigue. It is unclear which component behaviour change techniques (BCTs) contribute to the effectiveness of prescribing HIT implementations and optimisation. This study aimed to (i) quantitatively assess the HIT that reduces prescribing errors in hospitals and (ii) identify the BCTs associated with effective interventions. METHODS Articles were identified using CINAHL, EMBASE, MEDLINE, and Web of Science to May 2020. Eligible studies compared prescribing HIT with paper-order entry and examined prescribing error rates. Studies were excluded if prescribing error rates could not be extracted, if HIT use was non-compulsory or designed for one class of medication. The Newcastle-Ottawa scale was used to assess study quality. The review was reported in accordance with the PRISMA and SWiM guidelines. Odds ratios (OR) with 95% confidence intervals (CI) were calculated across the studies. Descriptive statistics were used to summarise effect estimates. Two researchers examined studies for BCTs using a validated taxonomy. Effectiveness ratios (ER) were used to determine the potential impact of individual BCTs. RESULTS Thirty-five studies of variable risk of bias and limited intervention reporting were included. TGE were identified in 31 studies. Compared with paper-order entry, prescribing HIT of varying sophistication was associated with decreased rates of prescribing errors (median OR 0.24, IQR 0.03-0.57). Ten BCTs were present in at least two successful interventions and may be effective components of prescribing HIT implementation and optimisation including prescriber involvement in system design, clinical colleagues as trainers, modification of HIT in response to feedback, direct observation of prescriber workflow, monitoring of electronic orders to detect errors, and system alerts that prompt the prescriber. CONCLUSIONS Prescribing HIT is associated with a reduction in prescribing errors in a variety of hospital settings. Poor reporting of intervention delivery and content limited the BCT analysis. More detailed reporting may have identified additional effective intervention components. Effective BCTs may be considered in the design and development of prescribing HIT and in the reporting and evaluation of future studies in this area.
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Affiliation(s)
- Joan Devin
- RCSI School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland.
| | - Brian J Cleary
- RCSI School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland.,Department of Pharmacy, The Rotunda Hospital, Parnell Square, Dublin 1, Ireland
| | - Shane Cullinan
- RCSI School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland
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Qian S, Munyisia E, Reid D, Hailey D, Pados J, Yu P. Trend in data errors after the implementation of an electronic medical record system: A longitudinal study in an Australian regional Drug and Alcohol Service. Int J Med Inform 2020; 144:104292. [DOI: 10.1016/j.ijmedinf.2020.104292] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 09/25/2020] [Accepted: 09/29/2020] [Indexed: 10/23/2022]
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Yoo J, Lee J, Rhee PL, Chang DK, Kang M, Choi JS, Bates DW, Cha WC. Alert Override Patterns With a Medication Clinical Decision Support System in an Academic Emergency Department: Retrospective Descriptive Study. JMIR Med Inform 2020; 8:e23351. [PMID: 33146626 PMCID: PMC7673981 DOI: 10.2196/23351] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 09/12/2020] [Accepted: 10/21/2020] [Indexed: 11/13/2022] Open
Abstract
Background Physicians’ alert overriding behavior is considered to be the most important factor leading to failure of computerized provider order entry (CPOE) combined with a clinical decision support system (CDSS) in achieving its potential adverse drug events prevention effect. Previous studies on this subject have focused on specific diseases or alert types for well-defined targets and particular settings. The emergency department is an optimal environment to examine physicians’ alert overriding behaviors from a broad perspective because patients have a wider range of severity, and many receive interdisciplinary care in this environment. However, less than one-tenth of related studies have targeted this physician behavior in an emergency department setting. Objective The aim of this study was to describe alert override patterns with a commercial medication CDSS in an academic emergency department. Methods This study was conducted at a tertiary urban academic hospital in the emergency department with an annual census of 80,000 visits. We analyzed data on the patients who visited the emergency department for 18 months and the medical staff who treated them, including the prescription and CPOE alert log. We also performed descriptive analysis and logistic regression for assessing the risk factors for alert overrides. Results During the study period, 611 physicians cared for 71,546 patients with 101,186 visits. The emergency department physicians encountered 13.75 alerts during every 100 orders entered. Of the total 102,887 alerts, almost two-thirds (65,616, 63.77%) were overridden. Univariate and multivariate logistic regression analyses identified 21 statistically significant risk factors for emergency department physicians’ alert override behavior. Conclusions In this retrospective study, we described the alert override patterns with a medication CDSS in an academic emergency department. We found relatively low overrides and assessed their contributing factors, including physicians’ designation and specialty, patients’ severity and chief complaints, and alert and medication type.
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Affiliation(s)
- Junsang Yoo
- Institution of Healthcare Resource, School of Nursing, Sahmyook University, Seoul, Republic of Korea
| | - Jeonghoon Lee
- Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Department of Digital Health, Sungkyunkwan University, Seoul, Republic of Korea
| | - Poong-Lyul Rhee
- Department of Gastroenterology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Kyung Chang
- Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Department of Digital Health, Sungkyunkwan University, Seoul, Republic of Korea.,Department of Gastroenterology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Health Information and Strategy Center, Samsung Medical Center, Seoul, Republic of Korea
| | - Mira Kang
- Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Department of Digital Health, Sungkyunkwan University, Seoul, Republic of Korea.,Health Information and Strategy Center, Samsung Medical Center, Seoul, Republic of Korea.,Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jong Soo Choi
- Health Information and Strategy Center, Samsung Medical Center, Seoul, Republic of Korea
| | - David W Bates
- Division of General Internal Meidicine and Primary Care, Brigham and Women's Hospital, Boston, MA, United States
| | - Won Chul Cha
- Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Department of Digital Health, Sungkyunkwan University, Seoul, Republic of Korea.,Health Information and Strategy Center, Samsung Medical Center, Seoul, Republic of Korea.,Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Snyder ME, Adeoye-Olatunde OA, Gernant SA, DiIulio J, Jaynes HA, Doucette WR, Russ-Jara AL. A user-centered evaluation of medication therapy management alerts for community pharmacists: Recommendations to improve usability and usefulness. Res Social Adm Pharm 2020; 17:1433-1443. [PMID: 33250363 DOI: 10.1016/j.sapharm.2020.10.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 09/14/2020] [Accepted: 10/28/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Community pharmacists provide comprehensive medication reviews (CMRs) through pharmacy contracts with medication therapy management (MTM) vendors. These CMRs are documented in the vendors' web-based MTM software platforms, which often integrate alerts to assist pharmacists in the detection of medication therapy problems. Understanding pharmacists' experiences with MTM alerts is critical to optimizing alert design for patient care. OBJECTIVES The objectives of this study were to 1) assess the usability and usefulness of MTM alerts for MTM vendor-contracted community pharmacists and 2) generate recommendations for improving MTM alerts for use by community pharmacists. METHODS This was a convergent, parallel mixed-methods evaluation of data collected from 3 sources, with individual pharmacists contributing data to one or more sources: 1) community pharmacists' submissions of observational data about MTM alerts encountered during routine MTM provision, 2) videos of naturalistic usability testing of MTM alerts, and 3) semi-structured interviews to elicit pharmacists' perspectives on MTM alert usefulness and usability. MTM alert data submitted by pharmacists were summarized with descriptive statistics. Usability testing videos were analyzed to determine pharmacists' time spent on MTM alerts and to identify negative usability incidents. Interview transcripts were analyzed using a hybrid approach of deductive and inductive codes to identify emergent themes. Triangulation of data (i.e., determination of convergence/divergence in findings across all data sources) occurred through investigator discussion and identified overarching findings pertaining to key MTM alert challenges. These resulted in actionable recommendations to improve MTM alerts for use by community pharmacists. RESULTS Collectively, two and four overarching key challenges pertaining to MTM alert usability and usefulness, respectively, were identified, resulting in 15 actionable recommendations for improving the design of MTM alerts from a user-centered perspective. CONCLUSIONS Recommendations are expected to inform enhanced MTM alert designs that can improve pharmacist efficiency, patient and prescriber satisfaction with MTM, and patient outcomes.
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Affiliation(s)
- Margie E Snyder
- Purdue University College of Pharmacy, Fifth Third Bank Building, 640 Eskenazi Avenue, Indianapolis, IN, 46202, USA.
| | - Omolola A Adeoye-Olatunde
- Purdue University College of Pharmacy, Fifth Third Bank Building, 640 Eskenazi Avenue, Indianapolis, IN, 46202, USA.
| | - Stephanie A Gernant
- University of Connecticut School of Pharmacy, 69 North Eagleville Rd, U-3095, Storrs, CT, 06269, USA.
| | - Julie DiIulio
- Applied Decision Science, 1776 Mentor Ave. #424, Cincinnati, OH, 45212, USA.
| | - Heather A Jaynes
- Purdue University College of Pharmacy, Fifth Third Bank Building, 640 Eskenazi Avenue, Indianapolis, IN, 46202, USA.
| | - William R Doucette
- University of Iowa College of Pharmacy, 339 CPB 180 S. Grand Avenue, Iowa City, IA, 52242, USA.
| | - Alissa L Russ-Jara
- Purdue University College of Pharmacy, Fifth Third Bank Building, 640 Eskenazi Avenue, Indianapolis, IN, 46202, USA.
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Development of a Taxonomy for Medication-Related Patient Safety Events Related to Health Information Technology in Pediatrics. Appl Clin Inform 2020; 11:714-724. [PMID: 33113568 DOI: 10.1055/s-0040-1717084] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Although electronic health records (EHRs) are designed to improve patient safety, they have been associated with serious patient harm. An agreed-upon and standard taxonomy for classifying health information technology (HIT) related patient safety events does not exist. OBJECTIVES We aimed to develop and evaluate a taxonomy for medication-related patient safety events associated with HIT and validate it using a set of events involving pediatric patients. METHODS We performed a literature search to identify existing classifications for HIT-related safety events, which were assessed using real-world pediatric medication-related patient safety events extracted from two sources: patient safety event reporting system (ERS) reports and information technology help desk (HD) tickets. A team of clinical and patient safety experts used iterative tests of change and consensus building to converge on a single taxonomy. The final devised taxonomy was applied to pediatric medication-related events assess its characteristics, including interrater reliability and agreement. RESULTS Literature review identified four existing classifications for HIT-related patient safety events, and one was iteratively adapted to converge on a singular taxonomy. Safety events relating to usability accounted for a greater proportion of ERS reports, compared with HD tickets (37 vs. 20%, p = 0.022). Conversely, events pertaining to incorrect configuration accounted for a greater proportion of HD tickets, compared with ERS reports (63 vs. 8%, p < 0.01). Interrater agreement (%) and reliability (kappa) were 87.8% and 0.688 for ERS reports and 73.6% and 0.556 for HD tickets, respectively. DISCUSSION A standardized taxonomy for medication-related patient safety events related to HIT is presented. The taxonomy was validated using pediatric events. Further evaluation can assess whether the taxonomy is suitable for nonmedication-related events and those occurring in other patient populations. CONCLUSION Wider application of standardized taxonomies will allow for peer benchmarking and facilitate collaborative interinstitutional patient safety improvement efforts.
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MacKenna B, Bacon S, Walker AJ, Curtis HJ, Croker R, Goldacre B. Impact of Electronic Health Record Interface Design on Unsafe Prescribing of Ciclosporin, Tacrolimus, and Diltiazem: Cohort Study in English National Health Service Primary Care. J Med Internet Res 2020; 22:e17003. [PMID: 33064085 PMCID: PMC7600019 DOI: 10.2196/17003] [Citation(s) in RCA: 241] [Impact Index Per Article: 60.3] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 02/11/2020] [Accepted: 02/29/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In England, national safety guidance recommends that ciclosporin, tacrolimus, and diltiazem are prescribed by brand name due to their narrow therapeutic windows and, in the case of tacrolimus, to reduce the chance of organ transplantation rejection. Various small studies have shown that changes to electronic health record (EHR) system interfaces can affect prescribing choices. OBJECTIVE Our objectives were to assess variation by EHR systems in breach of safety guidance around prescribing of ciclosporin, tacrolimus, and diltiazem, and to conduct user-interface research into the causes of such breaches. METHODS We carried out a retrospective cohort study using prescribing data in English primary care. Participants were English general practices and their respective EHR systems. The main outcome measures were (1) the variation in ratio of safety breaches to adherent prescribing in all practices and (2) the description of observations of EHR system usage. RESULTS A total of 2,575,411 prescriptions were issued in 2018 for ciclosporin, tacrolimus, and diltiazem (over 60 mg); of these, 316,119 prescriptions breached NHS guidance (12.27%). Breaches were most common among users of the EMIS EHR system (breaches in 18.81% of ciclosporin and tacrolimus prescriptions and in 17.99% of diltiazem prescriptions), but breaches were observed in all EHR systems. CONCLUSIONS Design choices in EHR systems strongly influence safe prescribing of ciclosporin, tacrolimus, and diltiazem, and breaches are prevalent in general practices in England. We recommend that all EHR vendors review their systems to increase safe prescribing of these medicines in line with national guidance. Almost all clinical practice is now mediated through an EHR system; further quantitative research into the effect of EHR system design on clinical practice is long overdue.
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Affiliation(s)
- Brian MacKenna
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Sebastian Bacon
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Alex J Walker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Helen J Curtis
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Richard Croker
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Ben Goldacre
- The DataLab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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Canfield C, Udeh C, Blonsky H, Hamilton AC, Fertel BS. Limiting the number of open charts does not impact wrong patient order entry in the emergency department. J Am Coll Emerg Physicians Open 2020; 1:1071-1077. [PMID: 33145560 PMCID: PMC7593465 DOI: 10.1002/emp2.12129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 04/30/2020] [Accepted: 05/11/2020] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE We sought to examine the impact of limiting the number of open active charts on wrong patient order entry events among 13 emergency departments (EDs) in a large integrated health system. METHODS A retrospective chart review of all orders placed between September 2017 and September 2019 was conducted. The rate of retract and reorder events was analyzed with no overlap in both the period pre- and post-intervention period. Secondary analysis of error rate by clinician type, clinician patient load, and time of day was performed. RESULTS The order retraction rate was not improved pre- and post-intervention. Retraction rates varied by clinician type with residents retracting more often than physicians (odds ratio [OR] = 1.443 [1.349, 1.545]). Advanced practice providers also showed a slightly higher rate than physicians (OR = 1.114 [1.071, 1.160]). Pharmacists showed very low rates compared to physicians (OR = 0.191 [0.048, 0.764]). Time of day and staffing ratios appear to be a factor with wrong patient order entry rates slightly lower during the night (1900-0700) than the day (OR 0.958 [0.923, 0.995]), and increasing slightly with every additional patient per provider (OR 1.019 [1.005, 1.032]). The Academic Medical Center had more retractions that the other EDs. OR for the various ED types compared to the Academic Medical Center included Community (OR 0.908 [0.859, 0.959]), Teaching Hospitals (OR 0.850 [0.802, 0.900]), and Freestanding (OR 0.932 [0.864, 1.006]). CONCLUSIONS Limiting the number of open active charts from 4 to 2 did not significantly reduce the incidence of wrong patient order entry. Further investigation into other factors contributing to order entry errors is warranted.
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Affiliation(s)
| | - Chiedozie Udeh
- Department of Cardiothoracic Anesthesia & Intensive Care and ResuscitationCleveland Clinic Health SystemCleveland Clinic Lerner College of MedicineClevelandOhioUSA
| | - Heather Blonsky
- Enterprise Quality and SafetyCleveland Clinic Health SystemClevelandOhioUSA
| | - Aaron C. Hamilton
- Department of Hospital Medicine & Enterprise Quality and SafetyCleveland Clinic Health SystemCleveland Clinic Lerner College of MedicineClevelandOhioUSA
| | - Baruch S. Fertel
- Department of Emergency Medicine & Enterprise Quality and SafetyCleveland Clinic Health SystemCleveland Clinic Lerner College of MedicineClevelandOhioUSA
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Suboptimal prescribing behaviour associated with clinical software design features: a retrospective cohort study in English NHS primary care. Br J Gen Pract 2020; 70:e636-e643. [PMID: 32784218 DOI: 10.3399/bjgp20x712313] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 02/16/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Electronic health record (EHR) systems are used by clinicians to record patients' medical information, and support clinical activities such as prescribing. In England, healthcare professionals are advised to 'prescribe generically' because generic drugs are usually cheaper than branded alternatives, and have fixed reimbursement costs. 'Ghost-branded generics' are a new category of medicines savings, caused by prescribers specifying a manufacturer for a generic product, often resulting in a higher reimbursement price compared with the true generic. AIM To describe time trends and practice factors associated with excess medication costs from ghost-branded generic prescribing. DESIGN AND SETTING Retrospective cohort study of English GP prescribing data and EHR deployment data. METHOD A retrospective cohort study was conducted, based on data from the OpenPrescribing.net database from May 2013 to May 2019. Total spending on ghost-branded generics across England was calculated, and excess spend on ghost-branded generics calculated as a percentage of all spending on generics for every CCG and general practice in England, for every month in the study period. RESULTS There were 31.8 million ghost-branded generic items and £9.5 million excess cost in 2018, compared with 7.45 million ghost-branded generic items and £1.3 million excess cost in 2014. Most excess costs were associated with one EHR, SystmOne, and it was identified that SystmOne offered ghost-branded generic options as the default. After informing the vendor, the authors monitored for subsequent change in costs, and report a rapid decrease in ghost-branded generic expenditure. CONCLUSION A design choice in a commonly used EHR has led to £9.5 million in avoidable excess prescribing costs for the NHS in 1 year. Notifying the vendor led to a change in user interface and a rapid, substantial spend reduction. This finding illustrates that EHR user interface design has a substantial impact on the quality, safety, and cost-effectiveness of clinical practice; this should be a priority for quantitative research.
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Elshayib M, Pawola L. Computerized provider order entry-related medication errors among hospitalized patients: An integrative review. Health Informatics J 2020; 26:2834-2859. [PMID: 32744148 DOI: 10.1177/1460458220941750] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The Institute of Medicine estimates that 7,000 lives are lost yearly as a result of medication errors. Computerized physician and/or provider order entry was one of the proposed solutions to overcome this tragic issue. Despite some promising data about its effectiveness, it has been found that computerized provider order entry may facilitate medication errors.The purpose of this review is to summarize current evidence of computerized provider order entry -related medication errors and address the sociotechnical factors impacting the safe use of computerized provider order entry. By using PubMed and Google Scholar databases, a systematic search was conducted for articles published in English between 2007 and 2019 regarding the unintended consequences of computerized provider order entry and its related medication errors. A total of 288 articles were screened and categorized based on their use within the review. One hundred six articles met our pre-defined inclusion criteria and were read in full, in addition to another 27 articles obtained from references. All included articles were classified into the following categories: rates and statistics on computerized provider order entry -related medication errors, types of computerized provider order entry -related unintended consequences, factors contributing to computerized provider order entry failure, and recommendations based on addressing sociotechnical factors. Identifying major types of computerized provider order entry -related unintended consequences and addressing their causes can help in developing appropriate strategies for safe and effective computerized provider order entry. The interplay between social and technical factors can largely affect its safe implementation and use. This review discusses several factors associated with the unintended consequences of this technology in healthcare settings and presents recommendations for enhancing its effectiveness and safety within the context of sociotechnical factors.
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Morquin D. [Legitimate resistance without technophobia: Analysis of electronic medical records impacts on the medical profession]. Rev Med Interne 2020; 41:617-621. [PMID: 32467002 DOI: 10.1016/j.revmed.2020.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 02/09/2020] [Accepted: 03/06/2020] [Indexed: 10/24/2022]
Abstract
The objective of this short narrative literature review is to highlight the different difficulties encountered by medical doctor in the daily use of EMR. We show that these are not simple transitional phenomena related to a "resistance to change", but rather the fact of a deeper and unfinished transformation. Beyond the "perception of misfit with work processes" or the threat of a loss of autonomy, we propose to analyze this so-called "resistance" in relation to the formalization of medical work induced by EMR. Our question concerns the compatibility of the multiple objectives of EMR, the potential influence of computerization on the steps of entering and consulting medical information, the impact on the clinical reasoning, the reality of assistance to medical "performance". The question is not so much what EMRs do less well than the paper record, but to provide insights into how tomorrow's EMRs will do better than today's.
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Affiliation(s)
- D Morquin
- Département des Maladies Infectieuses et Tropicales - CHU de Montpellier, Hôpital Gui de Chauliac, 80 avenue Augustin Fliche, 34295 Montpellier, France; Délégation à l'Usage clinique du Numérique, CHU de Montpellier - Hôpital Gui de Chauliac, 80 avenue Augustin Fliche, 34295 Montpellier, France.
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Roggeveen LF, Guo T, Driessen RH, Fleuren LM, Thoral P, van der Voort PHJ, Girbes ARJ, Bosman RJ, Elbers P. Right Dose, Right Now: Development of AutoKinetics for Real Time Model Informed Precision Antibiotic Dosing Decision Support at the Bedside of Critically Ill Patients. Front Pharmacol 2020; 11:646. [PMID: 32499697 PMCID: PMC7243359 DOI: 10.3389/fphar.2020.00646] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 04/22/2020] [Indexed: 12/17/2022] Open
Abstract
Introduction Antibiotic dosing in critically ill patients is challenging because their pharmacokinetics (PK) are altered and may change rapidly with disease progression. Standard dosing frequently leads to inadequate PK exposure. Therapeutic drug monitoring (TDM) offers a potential solution but requires sampling and PK knowledge, which delays decision support. It is our philosophy that antibiotic dosing support should be directly available at the bedside through deep integration into the electronic health record (EHR) system. Therefore we developed AutoKinetics, a clinical decision support system (CDSS) for real time, model informed precision antibiotic dosing. Objective To provide a detailed description of the design, development, validation, testing, and implementation of AutoKinetics. Methods We created a development framework and used workflow analysis to facilitate integration into popular EHR systems. We used a development cycle to iteratively adjust and expand AutoKinetics functionalities. Furthermore, we performed a literature review to select and integrate pharmacokinetic models for five frequently prescribed antibiotics for sepsis. Finally, we tackled regulatory challenges, in particular those related to the Medical Device Regulation under the European regulatory framework. Results We developed a SQL-based relational database as the backend of AutoKinetics. We developed a data loader to retrieve data in real time. We designed a clinical dosing algorithm to find a dose regimen to maintain antibiotic pharmacokinetic exposure within clinically relevant safety constraints. If needed, a loading dose is calculated to minimize the time until steady state is achieved. Finally, adaptive dosing using Bayesian estimation is applied if plasma levels are available. We implemented support for five extensively used antibiotics following model development, calibration, and validation. We integrated AutoKinetics into two popular EHRs (Metavision, Epic) and developed a user interface that provides textual and visual feedback to the physician. Conclusion We successfully developed a CDSS for real time model informed precision antibiotic dosing at the bedside of the critically ill. This holds great promise for improving sepsis outcome. Therefore, we recently started the Right Dose Right Now multi-center randomized control trial to validate this concept in 420 patients with severe sepsis and septic shock.
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Affiliation(s)
- Luca F Roggeveen
- Department of Intensive Care Medicine, Amsterdam Medical Data Science (AMDS), Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Tingjie Guo
- Department of Intensive Care Medicine, Amsterdam Medical Data Science (AMDS), Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Ronald H Driessen
- Department of Intensive Care Medicine, Amsterdam Medical Data Science (AMDS), Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Lucas M Fleuren
- Department of Intensive Care Medicine, Amsterdam Medical Data Science (AMDS), Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Patrick Thoral
- Department of Intensive Care Medicine, Amsterdam Medical Data Science (AMDS), Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | | | - Armand R J Girbes
- Department of Intensive Care Medicine, Amsterdam Medical Data Science (AMDS), Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Rob J Bosman
- Intensive Care Unit, OLVG Oost, Amsterdam, Netherlands
| | - Paul Elbers
- Department of Intensive Care Medicine, Amsterdam Medical Data Science (AMDS), Research VUmc Intensive Care (REVIVE), Amsterdam Cardiovascular Science (ACS), Amsterdam Infection and Immunity Institute (AI&II), Amsterdam UMC, Location VUmc, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
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Colicchio TK, Cimino JJ. Clinicians' reasoning as reflected in electronic clinical note-entry and reading/retrieval: a systematic review and qualitative synthesis. J Am Med Inform Assoc 2020; 26:172-184. [PMID: 30576561 DOI: 10.1093/jamia/ocy155] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 10/27/2018] [Indexed: 11/14/2022] Open
Abstract
Objective To describe the literature exploring the use of electronic health record (EHR) systems to support creation and use of clinical documentation to guide future research. Materials and Methods We searched databases including MEDLINE, Scopus, and CINAHL from inception to April 20, 2018, for studies applying qualitative or mixed-methods examining EHR use to support creation and use of clinical documentation. A qualitative synthesis of included studies was undertaken. Results Twenty-three studies met the inclusion criteria and were reviewed in detail. We briefly reviewed 9 studies that did not meet the inclusion criteria but provided recommendations for EHR design. We identified 4 key themes: purposes of electronic clinical notes, clinicians' reasoning for note-entry and reading/retrieval, clinicians' strategies for note-entry, and clinicians' strategies for note-retrieval/reading. Five studies investigated note purposes and found that although patient care is the primary note purpose, non-clinical purposes have become more common. Clinicians' reasoning studies (n = 3) explored clinicians' judgement about what to document and represented clinicians' thought process in cognitive pathways. Note-entry studies (n = 6) revealed that what clinicians document is affected by EHR interfaces. Lastly, note-retrieval studies (n = 12) found that "assessment and plan" is the most read note section and what clinicians read is affected by external stimuli, care/information goals, and what they know about the patient. Conclusion Despite the widespread adoption of EHRs, their use to support note-entry and reading/retrieval is still understudied. Further research is needed to investigate approaches to capture and represent clinicians' reasoning and improve note-entry and retrieval/reading.
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Affiliation(s)
- Tiago K Colicchio
- Informatics Institute, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - James J Cimino
- Informatics Institute, University of Alabama at Birmingham, Birmingham, Alabama, USA
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van der Zanden TM, de Hoog M, Windster JD, van Rosmalen J, van der Sijs IH, de Wildt SN. Does a Dose Calculator as an Add-On to a Web-Based Paediatric Formulary Reduce Calculation Errors in Paediatric Dosing? A Non-Randomized Controlled Study. Paediatr Drugs 2020; 22:229-239. [PMID: 32170636 PMCID: PMC7083797 DOI: 10.1007/s40272-020-00386-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
OBJECTIVES The structured digital dosing guidelines of the web-based Dutch Paediatric Formulary provided the opportunity to develop an integrated paediatric dose calculator. In a simulated setting, we tested the ability of this calculator to reduce calculation errors. METHODS Volunteer healthcare professionals were allocated to one of two groups, manual calculation versus the use of the dose calculator. Professionals in both groups were given access to a web-based questionnaire with 14 patient cases for which doses had to be calculated. The effect of group allocation on the probability of making a calculation error was determined using generalized estimated equations (GEE) logistic regression analysis. The causes of all the erroneous calculations were evaluated. RESULTS Seventy-seven healthcare professionals completed the web-based questionnaire: thirty-seven were allocated to the manual group and 40 to the calculator group. Use of the dose calculator resulted in an estimated mean probability of a calculation error of 24.4% (95% CI 16.3-34.8) versus 39.0% (95% CI 32.4-46.1) with use of manual calculation. The mean difference of probability of calculation error between groups was 14.6% (95% CI 3.1-26.2; p = 0.013). In a secondary analysis where calculation error was defined as a 10% or greater deviation from the correct answer, the corresponding figures were 19.5% (95% CI 13-28.2) versus 26.5% (95% CI 21.6-32.1) with a mean difference of 7% between groups (95% CI 2.2-16.3; p = 0.137). Juxtaposition, typo/transcription errors and non-specified errors were more frequent as cause of error in the calculator group; exceeding the maximum dose and wrong correction for age were more frequent in the manual group. The percentage of tenfold errors was 3.1% in the manual group and 3.7% in the calculator group. CONCLUSIONS Our study shows that the use of a dose calculator as an add-on to a web-based paediatric formulary can reduce calculation errors. Furthermore, it shows that technologies may introduce new errors through transcription errors and wrongly selecting parameters from drop-down lists. Therefore, dosing calculators should be developed and used with special attention for selection and transcription errors.
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Affiliation(s)
- Tjitske M. van der Zanden
- grid.416135.4Department of Paediatrics, Erasmus MC, Sophia Children’s Hospital, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands ,grid.5590.90000000122931605Department of Pharmacology and Toxicology, Radboud University, Nijmegen, The Netherlands ,Dutch Knowledge Center Pharmacotherapy for Children, The Hague, The Netherlands
| | - Matthijs de Hoog
- grid.416135.4Intensive Care and Department of Paediatrics, Erasmus MC, Sophia Children’s Hospital, Rotterdam, The Netherlands ,Dutch Knowledge Center Pharmacotherapy for Children, The Hague, The Netherlands
| | - Jonathan D. Windster
- grid.416135.4Intensive Care and Department of Paediatrics, Erasmus MC, Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Joost van Rosmalen
- grid.5645.2000000040459992XDepartment of Biostatistics, Erasmus MC, Rotterdam, The Netherlands
| | - I. Heleen van der Sijs
- grid.5645.2000000040459992XDepartment of Hospital Pharmacy, Erasmus MC, Rotterdam, The Netherlands
| | - Saskia N. de Wildt
- grid.416135.4Intensive Care and Department of Paediatrics, Erasmus MC, Sophia Children’s Hospital, Rotterdam, The Netherlands ,grid.5590.90000000122931605Department of Pharmacology and Toxicology, Radboud University, Nijmegen, The Netherlands ,Dutch Knowledge Center Pharmacotherapy for Children, The Hague, The Netherlands
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