Outcomes of computerized physician order entry in an electronic health record after implementation in an outpatient oncology setting

Computer programs used in the field of hospital pharmacy for the management of dangerous drugs: systematic review of literature

Background

This review wants to highlight the importance of computer programs used to control the steps in the management of dangerous drugs. It must be taken into account that there are phases in the process of handling dangerous medicines in pharmacy services that pose a risk to the healthcare personnel who handle them. Objective: To review the scientific literature to determine what computer programs have been used in the field of hospital pharmacy for the management of dangerous drugs (HDs).

Methods

The following electronic databases were searched from inception to July 30, 2021: MEDLINE (via PubMed), Embase, Cochrane Library, Scopus, Web of Science, Latin American and Caribbean Literature in Health Sciences (LILACS) and Medicine in Spanish (MEDES). The following terms were used in the search strategy: "Antineoplastic Agents," "Cytostatic Agents," "Hazardous Substances," "Medical Informatics Applications," "Mobile Applications," "Software," "Software Design," and "Pharmacy Service, Hospital."

Results

A total of 104 studies were retrieved form the databases, and 18 additional studies were obtained by manually searching the reference lists of the included studies and by consulting experts. Once the inclusion and exclusion criteria were applied, 26 studies were ultimately included in this review. Most of the applications described in the included studies were used for the management of antineoplastic drugs. The most commonly controlled stage was electronic prescription; 18 studies and 7 interventions carried out in the preparation stage focused on evaluating the accuracy of chemotherapy preparations.

Conclusion

Antineoplastic electronic prescription software was the most widely implemented software at the hospital level. No software was found to control the entire HD process. Only one of the selected studies measured safety events in workers who handle HDs. Moreover, health personnel were found to be satisfied with the implementation of this type of technology for daily work with these medications. All studies reviewed herein considered patient safety as their final objective. However, none of the studies evaluated the risk of HD exposure among workers.

Design, implementation, and evaluation of a CPOE system in a cancer care setting: A case study on the gastric cancer patients

BACKGROUND

Chemotherapy is a complex, multi-disciplinary, and error-prone process. Information technology is being increasingly used in different health care settings with complex work procedures such as cancer care to enhance the quality and safety of care. In this study, we aimed to develop a computerized physician order entry (CPOE) for chemotherapy prescribing in patients with gastric cancer and to evaluate the impact of CPOE on medication errors and order problems.

MATERIALS AND METHODS

A multi-disciplinary team consisting of a chemotherapy council group and system design and implementation team was formed for chemotherapy process evaluation, requirement analysis, developing computer-based protocols, and implementation of CPOE. A before and after study was conducted to evaluate the impact of CPOE on the chemotherapy process and medication errors and problem orders. To evaluate the level of end-user satisfaction, an ISO Norm 9241/110 usability questionnaire was chosen for the evaluation.

RESULTS

Before the implementation of the CPOE system, 37 medication errors (46.25%) and 53 problem orders (66.25%) were recorded for 80 paper-based chemotherapy prescriptions. After implementation of the CPOE system, 7 (8.7%) medication errors and 6 (7.5%) problem orders were recorded for 80 CPOE prescriptions. The implementation of CPOE reduced the medication error by 37.55% and the problematic order by 58.75%. The results for usability evaluation indicate that the CPOE was within the first class of the ISONORM level rating; this shows that a CPOE is with very high satisfaction and a very high functionality rate.

CONCLUSION

Developing a CPOE system significantly improved safety and quality of the chemotherapy process in cancer care settings by reducing the medication error, deleting unnecessary steps, improving communication and coordination between providers, and use of updated evidence-based medicine in direct chemotherapy orders. However, the CPOE system does not prevent all medication errors and may cause new errors. These errors can be human-related factors or associated with the design and implementation of the systems.

Impact of Computerized Provider Order Entry on Chemotherapy Medication Errors: A Systematic Review

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.

Design, Implementation, and Evaluation of Compliance With Pharmacy Workflow During a Pediatric Oncology Computerized Provider Order Entry (CPOE) Launch

OBJECTIVE

There is a lack of published literature detailing how computerized physician order entry (CPOE) pharmacy workflow is designed and implemented. The intent of this project was to design, implement, and assess compliance with the pharmacy workflow required for launching CPOE to improve the safety and efficiency of chemotherapy order entry for pediatric patients.

METHODS

This process implementation project took place in 2 phases, which included the design and implementation of pharmacy workflow education, and retrospective chart review of patients who received chemotherapy ordered through CPOE. An anonymous survey was also distributed to pharmacy staff, nurses, and physicians, and an assessment of any CPOE-related safety reports was completed.

RESULTS

Eighty-three patients received intravenous and/or intrathecal chemotherapy ordered via the CPOE software, Beacon, within the electronic medical record system, Epic, in the first 30 days post-launch across both the inpatient and outpatient settings. Overall compliance with the CPOE workflow for entering chemotherapy plans was 77% and >66% compliance with the order preparation process. Pharmacists provided an average of 1.6 interventions per review. The pharmacy was able to prepare chemotherapy within the allotted institutional time benchmarks in most cases. An overall combined multidisciplinary survey response rate of 30.6% was achieved. Twenty-eight Beacon-related patient safety reports were filed in the first 2 weeks post-launch.

CONCLUSIONS

The Beacon launch at this single pediatric institution was successful, and the pharmacy workflow was shown to greatly affect the overall success of the launch of CPOE. The careful prospective design, education, implementation, and retrospective review of the pharmacy workflow is key to process implementation related to chemotherapy CPOE.

Factors associated with nurse well-being in relation to electronic health record use: A systematic review

OBJECTIVE

Although nurses comprise the largest group of health professionals and electronic health record (EHR) user base, it is unclear how EHR use has affected nurse well-being. This systematic review assesses the multivariable (ie, organizational, nurse, and health information technology [IT]) factors associated with EHR-related nurse well-being and identifies potential improvements recommended by frontline nurses.

MATERIALS AND METHODS

We searched MEDLINE, Embase, CINAHL, PsycINFO, ProQuest, and Web of Science for literature reporting on EHR use, nurses, and well-being. A quality appraisal was conducted using a previously developed tool.

RESULTS

Of 4583 articles, 12 met inclusion criteria. Two-thirds of the studies were deemed to have a moderate or low risk of bias. Overall, the studies primarily focused on nurse- and IT-level factors, with 1 study examining organizational characteristics. That study found worse nurse well-being was associated with EHRs compared with paper charts. Studies on nurse-level factors suggest that personal digital literacy is one modifiable factor to improving well-being. Additionally, EHRs with integrated displays were associated with improved well-being. Recommendations for improving EHRs suggested IT-, organization-, and policy-level solutions to address the complex nature of EHR-related nurse well-being.

CONCLUSIONS

The overarching finding from this synthesis reveals a critical need for multifaceted interventions that better organize, manage, and display information for clinicians to facilitate decision making. Our study also suggests that nurses have valuable insight into ways to reduce EHR-related burden. Future research is needed to test multicomponent interventions that address these complex factors and use participatory approaches to engage nurses in intervention development.

Impact of computerised physician order entry (CPOE) on the incidence of chemotherapy-related medication errors: a systematic review

Purpose

Computerised prescriber (or physician) order entry (CPOE) implementation is one of the strategies to reduce medication errors. The extent to which CPOE influences the incidence of chemotherapy-related medication errors (CMEs) was not previously collated and systematically reviewed. Hence, this study was designed to collect, collate, and systematically review studies to evaluate the effect of CPOE on the incidence of CMEs.

Methods

A search was performed of four databases from 1 January 1995 until 1 August 2019. English-language studies evaluating the effect of CPOE on CMEs were selected as per inclusion and exclusion criteria. The total CMEs normalised to total prescriptions pre- and post-CPOE were extracted and collated to perform a meta-analysis using the ‘meta’ package in R. The systematic review was registered with PROSPERO CRD42018104220.

Results

The database search identified 1621 studies. After screening, 19 studies were selected for full-text review, of which 11 studies fulfilled the selection criteria. The meta-analysis of eight studies with a random effects model showed a risk ratio of 0.19 (95% confidence interval: 0.08–0.44) favouring CPOE (I² = 99%).

Conclusion

The studies have shown consistent reduction in CMEs after CPOE implementation, except one study that showed an increase in CMEs. The random effects model in the meta-analysis of eight studies showed that CPOE implementation reduced CMEs by 81%.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00228-021-03099-9.

Implementation of an integrated computerized prescriber order-entry system for chemotherapy in a multisite safety-net health system

PURPOSE

The development of a computerized prescriber order-entry (CPOE) system for chemotherapy in a multisite safety-net health system and the challenges to its successful implementation are described.

SUMMARY

Before CPOE for chemotherapy was first implemented and embedded in the electronic medical record system of Harris Health System (HHS), pharmacy personnel relied on regimen-specific preprinted order sets. However, due to differences in practice styles and workflow logistics, the paper orders across the 3 facilities were mostly site specific, with varying clinical content. Many of these order sets had not been approved by the oncology subcommittee. In addition, disparities in clinical knowledge and lack of communication contributed to inconsistencies in order set development. Led by medical directors from medical oncology departments at the 3 facilities, pharmacy administrators, and information technology representatives, HHS committed resources to supporting the adoption and use of a CPOE system for chemotherapy. Five practical lessons of broad applicability have been learned: engagement of interprofessional stakeholders, optimization of workflow before CPOE implementation, requirement of verification tool for CPOE, consolidation of protocols, and commitment to ongoing training and support. Evaluation of the CPOE system demonstrated a systemwide reduction in medication errors by 75% (p < 0.05). Satisfaction with the CPOE system varied among sites and was unchanged institutionwide 6 months after the CPOE implementation.

CONCLUSION

The development and implementation of CPOE for chemotherapy at a multisite safety-net health system created opportunities to optimize patient care and reduce variations through interprofessional collaborations. Initial evaluation suggested that CPOE reduced the medication-order error rate and improved user satisfaction in 1 of 3 facilities.

What to expect from electronic patient record system implementation: lessons learned from published evidence

Background

Numerous studies have examined factors related to success, failure and implications of electronic patient record (EPR) system implementations, but usually limited to specific aspects.

Objective

To review the published peer-reviewed literature and present findings regarding factors important in relation to successful EPR implementations and likely impact on subsequent clinical activity.

Method

Literature review.

Results

Three hundred and twelve potential articles were identified on initial search, of which 117 were relevant and included in the review. Several factors were related to implementation success, such as good leadership and management, infrastructure support, staff training and focus on workflows and usability. In general, EPR implementation is associated with improvements in documentation and screening performance and reduced prescribing errors, whereas there are minimal available data in other areas such as effects on clinical patient outcomes. The peer-reviewed literature appears to under-represent a range of technical factors important for EPR implementations, such as data migration from existing systems and impact of organisational readiness.

Conclusion

The findings presented here represent the synthesis of data from peer-reviewed literature in the field and should be of value to provide the evidence-base for organisations considering how best to implement an EPR system.

Endoplasmic reticulum stress mediates sulforaphane-induced apoptosis of HepG2 human hepatocellular carcinoma cells

Sulforaphane (SFN) is a naturally occurring chemopreventive agent, which effectively inhibits proliferation of HepG2 human hepatocellular carcinoma cells via mitochondria‑mediated apoptosis. Endoplasmic reticulum stress is considered the most important cause of cell apoptosis; therefore, the present study aimed to determine whether the endoplasmic reticulum pathway was involved in SFN-induced apoptosis of HepG2 cells. An MTT assay was used to detect the inhibitory effects of SFN on HepG2 cells. Fluorescence microscopy was used to observe the morphological changes in apoptotic cells, and western blot analysis was conducted to detect the expression of binding immunoglobulin protein (Bip)/glucose-regulated protein 78 (GRP78), X‑box binding protein‑1 (XBP‑1) and BH3 interacting domain death agonist (Bid). Furthermore, flow cytometry was used to determine the apoptotic rate of HepG2 cells, and the protein expression of C/EBP homologous protein (CHOP)/growth arrest‑ and DNA damage‑inducible gene 153 (GADD153) and caspase-12 in HepG2 cells. The results indicated that SFN significantly inhibited the proliferation of HepG2 cells; the half maximal inhibitory concentration values were 32.03±0.96, 20.90±1.96 and 13.87±0.44 µmol/l, following treatment with SFN for 24, 48 and 72 h, respectively. Following 48 h of SFN treatment (10, 20 and 40 µmol/l), the apoptotic rates of HepG2 cells were 31.8, 61.3 and 77.1%, respectively. Furthermore, after 48 h of exposure to SFN, the cells presented typical morphological alterations of apoptosis, as detected under fluorescence microscopy. Treatment with SFN for 48 h also significantly upregulated the protein expression levels of Bip/GRP78, XBP‑1, caspase‑12, CHOP/GADD153 and Bid in HepG2 cells. In conclusion, endoplasmic reticulum stress may be considered the most important mechanism underlying SFN-induced apoptosis in HepG2 cells.

A cancer care electronic medical record highly integrated into clinicians' workflow: users' attitudes pre-post implementation

The purpose was to study users' attitudes towards an electronic medical record (EMR) closely integrated into the clinicians' cancer care workflow. The EMR, implemented in an ambulatory cancer care centre, was designed as a care pathway information system providing real-time support to the coordination of shared care processes involving all the care personnel. Mixed method pre-post study design was used. The study population consisted of all care personnel. A survey measured the quality attributes of the EMR, the clinical information it produces, the perceived usefulness of the system for supporting clinical data management tasks and the perceived impacts in terms of access and quality of care. The survey shows that users' attitudes towards the EMR (response rate of 71%) measured after the go-live were positive ranging from 3.42 to 3.95 on a 5-point scale. Besides, the content analysis of 33 pre-post interviews revealed five main themes: magnitude of the changes caused by the EMR; its innovative potential; its positive benefits; an ongoing growth in users' expectancies; and the burden associated with the time required to operate the EMR. In sum, the study shows that users can largely apply innovative uses of information technologies that automate their clinical processes.

Data Quality Associated with Handwritten Laboratory Test Requests: Classification and Frequency of Data-Entry Errors for Outpatient Serology Tests

Objective:

Manual data-entry of handwritten laboratory test requests into electronic information systems has implications for data accuracy. This study sought to identify the types and number of errors occurring for handwritten serology test requests received from outpatient clinics.

Methods:

A 15-day audit at a serology laboratory in Sydney, Australia, compared the content of all transcribed serology outpatient test requests in the laboratory information system with the handwritten request form.

Results:

One or more errors were detected in 67/627 (10.7%) audited requests ( N=68 errors). Fifty-one of the errors (75.0%) were transcription errors: the wrong test was transcribed in 40/68 cases (58.8%) – ten of these occurred when the abbreviations ‘HBsAb’ and ‘HBsAg’ were confounded for one another – and transcribed requests were missing a test in 11/68 cases (16.2%). The remaining 17 non-transcription errors (25.0%) described request forms not signed by the ordering clinician, mislabelled specimens, and wrong tests due to computer algorithm errors.

Conclusions:

Manual data-entry of handwritten serology requests is an error-prone process. Electronic ordering has the potential to eliminate illegible handwriting and transcription errors, thus improving data accuracy in hospital information systems.

Chemotherapy e-prescribing: opportunities and challenges

Chemotherapy drugs are characterized by low therapeutic indices and significant toxicities at clinically prescribed doses, raising serious issues of drug safety. The safety of the chemotherapy medication use process is further challenged by regimen complexity and need to tailor treatment to patient status. Errors that occur during chemotherapy prescribing are associated with serious and life-threatening outcomes. Computerized provider order entry (CPOE) systems were shown to reduce overall medication errors in ambulatory and inpatient settings. The adoption of chemotherapy CPOE is lagging due to financial cost and cultural and technological challenges. Institutions that adopted infusional or oral chemotherapy electronic prescribing modified existing CPOE systems to allow chemotherapy prescribing, implemented chemotherapy-specific CPOE systems, or developed home-grown chemotherapy electronic prescribing programs. Implementation of chemotherapy electronic prescribing was associated with a significant reduction in the risk of prescribing errors, most significantly dose calculation and adjustment errors. In certain cases, implementation of chemotherapy CPOE was shown to improve the chemotherapy use process. The implementation of chemotherapy CPOE may increase the risk of new types of errors, especially if processes are not redesigned and adapted to CPOE. Organizations aiming to implement chemotherapy CPOE should pursue a multidisciplinary approach engaging all stakeholders to guide system selection and implementation. Following implementation, organizations should develop and use a risk assessment process to identify and evaluate unanticipated consequences and CPOE-generated errors. The results of these analyses should serve to further enhance the chemotherapy electronic prescribing process and improve the quality and safety of cancer care.

Exploring perceptions and use of the electronic health record by parents of children with autism spectrum disorder: A qualitative study

This qualitative project used structured interviews with nine parents to examine perceptions of the electronic health record (EHR) and associated patient portal in the treatment of their child's autism spectrum disorder. Thematic analysis identified six complementary themes including: Familiarity and exposure to the EHR, changing experience of care (streamlining appointments, providing more rapid medical record access, increasing clinician awareness of the complexity of their child's medical treatment, and facilitating prescriptions), portal use, patient/EHR/portal interaction, interoperability, and mother as care coordinator. While aware of the patient portal, only one-third had registered to use it and these parents reported only limited use. In general, perceptions of the electronic health record are positive, but the patient portal has yet to have needed consumer adoption. Further research and functionality are needed to increase portal registration and greater portal integration in patient care.

Health information technology in oncology practice: a literature review

The adoption and implementation of information technology are dramatically remodeling healthcare services all over the world, resulting in an unstoppable and sometimes overwhelming process. After the introduction of the main elements of electronic health records and a description of what every cancer-care professional should be familiar with, we present a narrative review focusing on the current use of computerized clinical information and decision systems in oncology practice. Following a detailed analysis of the many coveted goals that oncologists have reached while embracing informatics progress, the authors suggest how to overcome the main obstacles for a complete physicians' engagement and for a full information technology adoption, and try to forecast what the future holds.

Factors associated with adoption of health information technology: a conceptual model based on a systematic review

BACKGROUND

The Health Information Technology for Economic and Clinical Health Act (HITECH) allocated $19.2 billion to incentivize adoption of the electronic health record (EHR). Since 2009, Meaningful Use Criteria have dominated information technology (IT) strategy. Health care organizations have struggled to meet expectations and avoid penalties to reimbursements from the Center for Medicare and Medicaid Services (CMS). Organizational theories attempt to explain factors that influence organizational change, and many theories address changes in organizational strategy. However, due to the complexities of the health care industry, existing organizational theories fall short of demonstrating association with significant health care IT implementations. There is no organizational theory for health care that identifies, groups, and analyzes both internal and external factors of influence for large health care IT implementations like adoption of the EHR.

OBJECTIVE

The purpose of this systematic review is to identify a full-spectrum of both internal organizational and external environmental factors associated with the adoption of health information technology (HIT), specifically the EHR. The result is a conceptual model that is commensurate with the complexity of with the health care sector.

METHODS

We performed a systematic literature search in PubMed (restricted to English), EBSCO Host, and Google Scholar for both empirical studies and theory-based writing from 1993-2013 that demonstrated association between influential factors and three modes of HIT: EHR, electronic medical record (EMR), and computerized provider order entry (CPOE). We also looked at published books on organizational theories. We made notes and noted trends on adoption factors. These factors were grouped as adoption factors associated with various versions of EHR adoption.

RESULTS

The resulting conceptual model summarizes the diversity of independent variables (IVs) and dependent variables (DVs) used in articles, editorials, books, as well as quantitative and qualitative studies (n=83). As of 2009, only 16.30% (815/4999) of nonfederal, acute-care hospitals had adopted a fully interoperable EHR. From the 83 articles reviewed in this study, 16/83 (19%) identified internal organizational factors and 9/83 (11%) identified external environmental factors associated with adoption of the EHR, EMR, or CPOE. The conceptual model for EHR adoption associates each variable with the work that identified it.

CONCLUSIONS

Commonalities exist in the literature for internal organizational and external environmental factors associated with the adoption of the EHR and/or CPOE. The conceptual model for EHR adoption associates internal and external factors, specific to the health care industry, associated with adoption of the EHR. It becomes apparent that these factors have some level of association, but the association is not consistently calculated individually or in combination. To better understand effective adoption strategies, empirical studies should be performed from this conceptual model to quantify the positive or negative effect of each factor.

Toward successful migration to computerized physician order entry for chemotherapy

BACKGROUND

Computerized physician order entry (cpoe) systems allow for medical order management in a clinical setting. Use of a cpoe has been shown to significantly improve chemotherapy safety by reducing the number of prescribing errors. Usability of these systems has been identified as a critical factor in their successful adoption. However, there is a paucity of literature investigating the usability of cpoe for chemotherapy and describing the experiences of cancer care providers in implementing and using a cpoe system.

METHODS

A mixed-methods study, including a national survey and a workshop, was conducted to determine the current status of cpoe adoption in Canadian oncology institutions, to identify and prioritize knowledge gaps in cpoe usability and adoption, and to establish a research agenda to bridge those gaps. Survey respondents were representatives of cancer care providers from each Canadian province. The workshop participants were oncology clinicians, human factors engineers, patient safety researchers, policymakers, and hospital administrators from across Canada, with participation from the United States.

RESULTS

A variety of issues related to implementing and using a cpoe for chemotherapy were identified. The major issues concerned the need for better understanding of current practices of chemotherapy ordering, preparation, and administration; a lack of system selection and procurement guidance; a lack of implementation and maintenance guidance; poor cpoe usability and workflow support; and other cpoe system design issues. An additional three research themes for addressing the existing challenges and advancing successful adoption of cpoe for chemotherapy were identified: The need to investigate variances in workflows and practices in chemotherapy ordering and administrationThe need to develop best-practice cpoe procurement and implementation guidance specifically for chemotherapyThe need to measure the effects of cpoe implementation in medical oncology.

CONCLUSIONS

Addressing the existing challenges in cpoe usability and adoption for chemotherapy, and accelerating successful migration to cpoe by cancer care providers requires future research focusing on workflow variations, chemotherapy-specific cpoe procurement needs, and implementation guidance needs.

Chemotherapy prescribing errors: an observational study on the role of information technology and computerized physician order entry systems

BACKGROUND

Chemotherapy administration is a high-risk process. Aim of this study was to evaluate the frequency, type, preventability, as well as potential and actual severity of outpatient chemotherapy prescribing errors in an Oncology Department where electronic prescribing is used.

METHODS

Up to three electronic prescriptions per patient record were selected from the clinical records of consecutive patients who received cytotoxic chemotherapy between January 2007 and December 2008. Wrong prescriptions were classified as incomplete, incorrect or inappropriate. Error preventability was classified using a four-point scale. Severity was defined according to the Healthcare Failure Mode and Effect Analysis Severity Scale.

RESULTS

Eight hundred and thirty-five prescriptions were eligible. The overall error rate was 20%. Excluding systematic errors (i.e. errors due to an initially faulty implementation of chemotherapy protocols into computerized dictionaries) from the analysis, the error rate decreased to 8%. Incomplete prescriptions were the majority. Most errors were deemed definitely preventable. According to error presumptive potential for damage, 72% were classified as minor; only 3% had the potential to produce major or catastrophic injury. Sixty-eight percent were classified as near misses; adverse drug events had no or little effect on clinical outcome.

CONCLUSIONS

Chemotherapy prescribing errors may arise even using electronic prescribing. Although periodic audits may be useful to detect common errors and guide corrective actions, it is crucial to get the computerized physician order entry system and set-ups correct before implementation.

Evaluating an oncology systemic therapy computerized physician order entry system using international guidelines

Chemotherapy is prone to medication error resulting from complexities in ordering and administration. Computerized physician order entry (CPOE) has been established as an important tool to minimize such errors and hence improve patient safety. As a leading Canadian advisory body in oncology, Cancer Care Ontario (CCO) has been a champion in developing and implementing its own cancer systemic therapy CPOE, the Oncology Patient Information System (OPIS). This article reviews and consolidates principles for oncology CPOE systems as found in the literature and in guidelines created by three international oncology organizations (American Society of Clinical Oncology, Clinical Oncological Society of Australia, and CCO). It then evaluates OPIS by these standards and provides a working example of what a cancer CPOE system should look like. This document can therefore be used as a framework to help develop and evaluate cancer CPOE platforms in different national settings. As end users, oncologists are considered key stakeholders in developing such systems and thus should be well informed about CPOE principles to help make decisions on the appropriate implementation of these platforms in their local practice settings. In addition, oncologists are also important champions for the successful uptake of oncology CPOE platforms and would benefit from a better understanding of whether proposed or existing local CPOE systems meet established standards.

Antiemetic prescribing practices using a computerized physician order entry system

PURPOSE

Adherence to guideline-consistent chemotherapy-induced nausea and vomiting (CINV) prophylaxis is suboptimal. The primary aim of this study was to evaluate the magnitude of compliance to institutional guideline-directed antiemetic prophylaxis using a computerized physician order entry system at a single tertiary care institution. A nurse survey was also performed to evaluate how oncology practices, within a cooperative group, managed clinician orders for the prevention of CINV.

METHODS

The electronic medical records of 100 consecutive patients were evaluated. The primary endpoint was the incidence of compliance to provide all aspects of scheduled institutional guideline-directed antiemetic prophylaxis for acute (day 1) and delayed (days 2-4) CINV. A descriptive analysis was performed on the convenience sample. Logistic regression was completed to determine the predictors of noncompliance.

RESULTS

The incidence of compliance on days 1-4 was 94 %. Half of the noncompliant events (three of six, 50 %) occurred on day 1 alone and involved patients receiving low-emetogenic chemotherapy. There was a high degree of compliance to institutional guidelines for the treatment of delayed CINV (97 %). Patients receiving minimally emetogenic and moderately emetogenic chemotherapy (N = 70) were observed to be 100 % compliant. Patients receiving doxorubicin/cyclophosphamide were numerically less likely to receive institutional guidelines, compared to patients receiving other chemotherapy regimens (OR, 0.24 (0.04, 1.36), p value, 0.05). The nurse survey suggested significant variability amongst the involved institutions with regards to antiemetic prescribing practices.

CONCLUSIONS

Computerized physician order entry is associated with impressive adherence to clinician-prescribing practices, according to institutional guidelines, for acute and delayed CINV.

Reduction in chemotherapy order errors with computerized physician order entry

PURPOSE

To measure the number and type of errors associated with chemotherapy order composition associated with three sequential methods of ordering: handwritten orders, preprinted orders, and computerized physician order entry (CPOE) embedded in the electronic health record.

MATERIALS AND METHODS

From 2008 to 2012, a sample of completed chemotherapy orders were reviewed by a pharmacist for the number and type of errors as part of routine performance improvement monitoring. Error frequencies for each of the three distinct methods of composing chemotherapy orders were compared using statistical methods.

RESULTS

The rate of problematic order sets-those requiring significant rework for clarification-was reduced from 30.6% with handwritten orders to 12.6% with preprinted orders (preprinted v handwritten, P < .001) to 2.2% with CPOE (preprinted v CPOE, P < .001). The incidence of errors capable of causing harm was reduced from 4.2% with handwritten orders to 1.5% with preprinted orders (preprinted v handwritten, P < .001) to 0.1% with CPOE (CPOE v preprinted, P < .001).

CONCLUSION

The number of problem- and error-containing chemotherapy orders was reduced sequentially by preprinted order sets and then by CPOE. CPOE is associated with low error rates, but it did not eliminate all errors, and the technology can introduce novel types of errors not seen with traditional handwritten or preprinted orders. Vigilance even with CPOE is still required to avoid patient harm.

Development and implementation of a computerized system for collection, processing, and administration of cellular therapy products

Great strides have been made in computerization of ordering processes for general medications and chemotherapy agents. However, systems for ordering, processing, and administration of cellular therapies continue to be largely paper-based, without the safety features of computerized order entry. To address this deficit, Partners Healthcare System Information Services (PHS-IS; Boston, MA) has worked with oncologists and staff in the cell processing laboratory at the Dana-Farber Cancer Institute (Boston, MA) to develop and implement a novel, comprehensive computerized system for physician ordering and management of cellular products. A multidisciplinary team was formed to accomplish the task of developing a cellular product management system. This team identified the unique characteristics of cellular therapies and sought to develop a comprehensive computerized system that addressed these needs. The biotherapy order entry system developed and implemented by PHS-IS includes a suite of three interrelated applications that addresses all requirements of a traditional computerized provider order entry system, as well as features unique to cellular therapies. The biotherapy suite of applications has addressed patient safety concerns, streamlined the ordering of cellular therapy products, and has reduced opportunities for error and delay in product administration.

Improving electronic oral chemotherapy prescription: can we build a safer system?

INTRODUCTION

To prevent oral chemotherapy prescription errors, we enhanced a prescription-writing module in an ambulatory electronic medical record. We sought to describe the enhancement, examine its performance to date, and identify opportunities for improvement.

METHODS

Enhancements to the oral chemotherapy writing module included weight- and body surface area-based dosing, fields for cancer diagnosis and intent of therapy (curative v palliative), and dose-limit warnings. We studied all prescriptions for 18 oral chemotherapies generated by oncology clinicians during the first 17 months after the safe prescribing enhancements were introduced, from May 1, 2010, to October 1, 2011. We examined the frequency with which clinicians used the new features, the number and type of alerts generated, and clinician actions in response to alerts.

RESULTS

Six hundred clinicians generated 6,673 prescriptions for 2,043 patients. Six drugs-temozolomide, capecitabine, lenalidomide, hydroxyurea, imatinib, and erlotinib-accounted for 5,512 of all oral chemotherapy prescriptions (83%). Prescribers indicated the intent of therapy 13% of the time and listed the patient's cancer diagnosis 46% of the time. Prescribers customized their instructions using a free-text field in 64% of prescriptions. Clinicians' 6,673 prescription attempts triggered 395 dose-limit warnings (5%), mostly for temozolomide. Clinicians ignored most (96%) warnings, because current dosing recommendations exceeded the dose-limit warnings for the alerted medications.

CONCLUSION

Oncology clinicians readily accepted features designed to enhance oral chemotherapy safety. Additional enhancements are needed to facilitate prescriptions with complex dosing regimens and to provide dose-limit warnings that reflect current clinical practice.