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Phang KG, Wahlquist AE, Hayes G, Corrigan C, Basco WT, Bundy DG. Opioid Dosing Deviation and Dose Banding Development in Young Hospitalized Children. Hosp Pediatr 2024; 14:758-765. [PMID: 39193635 DOI: 10.1542/hpeds.2023-007619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 04/17/2024] [Accepted: 04/27/2024] [Indexed: 08/29/2024]
Abstract
BACKGROUND AND OBJECTIVES Individualized, weight-based opioid dosing poses safety risks and contributes to inefficient medication delivery processes. Dose banding is a patient safety strategy to reduce dosing errors through standardized doses based on weight ranges. Study objectives were (1) determine the frequency of dosing deviation from reference ranges of common intravenous (IV) and oral opioid medications, (2) evaluate the differences in dosing deviations by age, and (3) determine the potential reduction in dose variation that could be achieved by dose banding. METHODS We conducted a cross-sectional analysis of hospitalized children ≥2 months to ≤24 months old who received IV morphine, oral methadone, or oral oxycodone at a single center. Dosing was categorized as no dosing deviation (within ±5% of the reference range), negative dosing deviation (>5% below the reference range), or positive dosing deviation (>5% above the reference range). Descriptive and bivariate analyses were conducted. RESULTS A total of 3361 opioid doses met the inclusion criteria. A total of 2663 (79.2%) had no dosing deviation, 214 (6.3%) demonstrated negative deviations, and 484 (14.4%) demonstrated positive deviations. Dosing deviations were more frequent among subjects ≥2 months to ≤6 months old for oral methadone and oxycodone (P < .0001) and more frequent among older age group for IV morphine (P < .0001). Dose banding has the potential to reduce the number of unique doses prescribed for all medications by 75% while eliminating unintended dosing deviations. CONCLUSIONS A total of 20% of opioid doses prescribed to children ≤24 months of age are outside the recommended ranges. Dose banding represents a promising method for simplifying opioid prescribing in the pediatric inpatient setting.
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Affiliation(s)
- Karina G Phang
- Geisinger, Department of Pediatrics, Center for Pharmacy Innovations and Outcomes, Danville, Pennsylvania
| | - Amy E Wahlquist
- Center for Rural Health Research, Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, Tennessee
| | | | | | - William T Basco
- Medical University of South Carolina, Department of Pediatrics, Charleston, South Carolina
| | - David G Bundy
- Medical University of South Carolina, Department of Pediatrics, Charleston, South Carolina
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2
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Choukroun JF, Lee K, Rey A. Creating Meaningful Alerts and Reducing Alert Fatigue: Strategies Implemented by Informatics Pharmacists to Optimize Dose Range Checking Alerts in a Multihospital Health System. J Pharm Technol 2022; 38:319-325. [PMID: 36311305 PMCID: PMC9608100 DOI: 10.1177/87551225221117152] [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: 08/19/2023] Open
Abstract
Background: Among the many clinical decision support (CDS) mechanisms available in electronic health record (EHR) systems, dose range checking (DRC) is one of the most impactful safeguard tools integrated within most computerized provider order entry (CPOE) workflows. Unfortunately, improper configurations and lack of resources to maintain and monitor CDS systems can hinder and even disrupt daily clinical operations. Objective: This article seeks to highlight the impact that informatics pharmacists can make by implementing different strategies to decrease nuisance alerts and create clinically meaningful DRC alerts that guide clinicians in their practice. Methods: Following the activation of the DRC application for 3623 medication groupers (ie, generic drugs and all their dosage form variations), informatics pharmacists implemented strategies to monitor DRC alert output and decrease the number of inappropriate alerts. Such strategies included weekly monitoring of alerts, modification of order sentences (including dose, route, and age/weight filters), update to the rule triggering the alerts, and modifications of the preference settings. Results: From July to September 2018, an average of 70 DRC tables were reviewed by informatics pharmacists, reducing the number of overridden DRC alerts to 4796 in the first week of September-a 63% decrease in a 3-month period. Conclusions: By reducing the number of DRC nuisance alerts and improving the clinical content of DRC alerts, informatics pharmacists can contribute to lowering alert fatigue and improving providers' trust in CDS alerts.
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Affiliation(s)
| | - Kristina Lee
- Baptist Health South Florida, Coral Gables, FL, USA
| | - Aixa Rey
- Baptist Health South Florida, Coral Gables, FL, USA
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3
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Brown SV, Patterson R, Davidson T, Rozette NA. Evaluation of a Pharmacist-Driven Pediatric Dose Rounding Protocol. J Pediatr Pharmacol Ther 2022; 27:636-640. [DOI: 10.5863/1551-6776-27.7.636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 11/29/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE
Medication errors are 3 times more likely to occur in pediatric populations due to calculation and rounding errors. The objective of this study was to determine the effect of a pharmacist-driven pediatric dose rounding protocol on the dose rounding of medications, measurable volumes of inpatient and discharge prescriptions, and potential cost savings.
METHODS
This single center, quasi-experimental study evaluated patients younger than or equal to 18 years of age prescribed intravenous or enteral liquid medications during an inpatient, observation, or emergency department encounter. The primary outcome of rate of measurable dose volumes was evaluated pre- and post-implementation of the protocol. Secondary outcomes, including the number of discharge prescriptions affected by pharmacist dose rounding, an evaluation of protocol effect, and prescriptions dose rounded to limit the number of packages per dose, were evaluated using a cross-sectional analysis of the post-group.
RESULTS
Four hundred seventy-seven patients and 1060 medications were evaluated in a 1-month period. The rate of measurable volumes increased from 72% to 93% in the post-group (p = 0.0001). In the post-group, 197 patients had 313 medications dose rounded by pharmacists per protocol. Of the 55 discharge medications in the post-group, 21 prescriptions (38%) matched inpatient orders that had been dose rounded by pharmacists. Twenty-four medications were rounded down to a whole package size resulting in an estimated cost savings of $117 (approximately $1400 per year).
CONCLUSIONS
Implementation of a pharmacist-driven dose rounding protocol significantly increased the rate of measurable volumes administered to pediatric patients at our institution.
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Affiliation(s)
- Shannon V. Brown
- Department of Pharmacy (SVB, RP, TD, NAR), Carilion Roanoke Memorial Hospital and Carilion Children's Hospital, Roanoke, VA
| | - Richard Patterson
- Department of Pharmacy (SVB, RP, TD, NAR), Carilion Roanoke Memorial Hospital and Carilion Children's Hospital, Roanoke, VA
| | - Tamara Davidson
- Department of Pharmacy (SVB, RP, TD, NAR), Carilion Roanoke Memorial Hospital and Carilion Children's Hospital, Roanoke, VA
| | - Nicole A. Rozette
- Department of Pharmacy (SVB, RP, TD, NAR), Carilion Roanoke Memorial Hospital and Carilion Children's Hospital, Roanoke, VA
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4
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Lau J, Islam S, Polischuk E. Appropriateness and Accuracy of Antimicrobial Prescriptions at Pediatric Emergency Department Discharge. Clin Pediatr (Phila) 2022; 61:461-464. [PMID: 35369760 DOI: 10.1177/00099228221085879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Jackelyn Lau
- Oishei Children's Hospital, University at Buffalo, Buffalo, NY, USA
| | - Shamim Islam
- Oishei Children's Hospital, University at Buffalo, Buffalo, NY, USA
| | - Emily Polischuk
- Oishei Children's Hospital, University at Buffalo, Buffalo, NY, USA
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5
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Campbell CT, Wheatley KH, Svoboda L, Campbell CE, Norris KR. Strategies for Implementing Pediatric Dose Standardization: Considerations From the Vizient University Health System Consortium Pharmacy Network Pediatric Pharmacy Committee. J Pediatr Pharmacol Ther 2021; 27:19-28. [PMID: 35002555 PMCID: PMC8717617 DOI: 10.5863/1551-6776-27.1.19] [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: 07/24/2020] [Accepted: 01/05/2021] [Indexed: 11/11/2022]
Abstract
Pediatric patients are at a heightened risk for medication errors due to variability in medication ordering and administration. Dose rounding and standardization have been 2 practices historically used to reduce variability and improve medication safety. This article will describe strategies for implementing pediatric dose standardization. Local practice often dictates the operational decisions made at an institutional level, leading to a lack of a standard methodology. Vizient survey results demonstrate there is wide variation in dose standardization and ready-to-use (RTU) practices although most responding institutions have attempted to limit bedside manipulation to reduce medication error. There are many barriers to consider before pursuing dose standardization at an institution. These include selecting medications to standardize, calculating appropriate standardized doses, preparing RTU products, and supplying the products to the patient. Strategies to overcome implementation issues are described as well as identification of knowledge gaps related to the preparation and use of RTU products in the pediatric population. There is opportunity to enhance an institution's ability to provide RTU medications. Although there are several barriers, those that have had successful implementation have leveraged their information technology systems, garnered multidisciplinary support, and customized their practice to meet their operational demands.
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Affiliation(s)
| | | | - Leanne Svoboda
- Department of Pharmacy (LS), New York Presbyterian Hospital, New York City, NY
| | - Courtney E. Campbell
- Department of Pharmacy (CTC, CEC, KRN), Augusta University Medical Center, Augusta, GA
| | - Kelley R. Norris
- Department of Pharmacy (CTC, CEC, KRN), Augusta University Medical Center, Augusta, GA
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6
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Yin HS, Neuspiel DR, Paul IM, Franklin W, Tieder JS, Adirim T, Alvarez F, Brown JM, Bundy DG, Ferguson LE, Gleeson SP, Leu M, Mueller BU, Connor Phillips S, Quinonez RA, Rea C, Rinke ML, Shaikh U, Shiffman RN, Vickers Saarel E, Spencer Cockerham SP, Mack Walsh K, Jones B, Adler AC, Foster JH, Green TP, Houck CS, Laughon MM, Neville K, Reigart JR, Shenoi R, Sullivan JE, Van Den Anker JN, Verhoef PA. Preventing Home Medication Administration Errors. Pediatrics 2021; 148:183379. [PMID: 34851406 DOI: 10.1542/peds.2021-054666] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Medication administration errors that take place in the home are common, especially when liquid preparations are used and complex medication schedules with multiple medications are involved; children with chronic conditions are disproportionately affected. Parents and other caregivers with low health literacy and/or limited English proficiency are at higher risk for making errors in administering medications to children in their care. Recommended strategies to reduce home medication errors relate to provider prescribing practices; health literacy-informed verbal counseling strategies (eg, teachback and showback) and written patient education materials (eg, pictographic information) for patients and/or caregivers across settings (inpatient, outpatient, emergency care, pharmacy); dosing-tool provision for liquid medication measurement; review of medication lists with patients and/or caregivers (medication reconciliation) that includes prescription and over-the-counter medications, as well as vitamins and supplements; leveraging the medical home; engaging adolescents and their adult caregivers; training of providers; safe disposal of medications; regulations related to medication dosing tools, labeling, packaging, and informational materials; use of electronic health records and other technologies; and research to identify novel ways to support safe home medication administration.
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Affiliation(s)
- H Shonna Yin
- Departments of Pediatrics and Population Health, Grossman School of Medicine, New York University, New York, New York
| | | | - Ian M Paul
- Departments of Pediatrics and Public Health Sciences, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania
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7
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Philips K, Zhou R, Lee DS, Marrese C, Nazif J, Browne C, Sinnett M, Tuckman S, Modi A, Rinke ML. Implementation of a Standardized Approach to Improve the Pediatric Discharge Medication Process. Pediatrics 2021; 147:peds.2019-2711. [PMID: 33408070 PMCID: PMC7849199 DOI: 10.1542/peds.2019-2711] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/23/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The pediatric inpatient discharge medication process is complicated, and caregivers have difficulty managing instructions. Authors of few studies evaluate systematic processes for ensuring quality in these care transitions. We aimed to improve caregiver medication management and understanding of discharge medications by standardizing the discharge medication process. METHODS An interprofessional team at an urban, tertiary care children's hospital trialed interventions to improve caregiver medication management and understanding. These included mnemonics to aid in complete medication counseling, electronic medical record enhancements to standardize medication documentation and simplify dose rounding, and housestaff education. The primary outcome measure was the proportion of discharge medication-related failures in each 4-week period. Failure was defined as an incorrect response on ≥1 survey questions. Statistical process control was used to analyze improvement over time. Process measures related to medication documentation and dose rounding were compared by using the χ2 test and process control. RESULTS Special cause variation occurred in the mean discharge medication-related failure rate, which decreased from 70.1% to 36.1% and was sustained. There were significantly more complete after-visit summaries (21.0% vs 85.1%; P < .001) and more patients with simplified dosing (75.2% vs 95.6%; P < .001) in the intervention period. Special cause variation also occurred for these measures. CONCLUSIONS A systematic approach to standardizing the discharge medication process led to improved caregiver medication management and understanding after pediatric inpatient discharge. These changes could be adapted by other hospitals to enhance the quality of this care transition.
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Affiliation(s)
- Kaitlyn Philips
- Children's Hospital at Montefiore, Bronx, New York; .,Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
| | - Roy Zhou
- NewYork-Presbyterian Queens Hospital, Flushing, New York
| | - Diana S. Lee
- Mount Sinai Kravis Children’s Hospital, New York, New York; and
| | - Christine Marrese
- Baystate Children’s Hospital, Baystate Medical Center, Springfield, Massachusetts
| | - Joanne Nazif
- Children’s Hospital at Montefiore, Bronx, New York;,Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
| | | | - Mark Sinnett
- Children’s Hospital at Montefiore, Bronx, New York
| | | | - Anjali Modi
- Children’s Hospital at Montefiore, Bronx, New York
| | - Michael L. Rinke
- Children’s Hospital at Montefiore, Bronx, New York;,Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
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8
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Rashed AN, Tomlin S. Establishing dose bands for commonly prescribed oral medications for children in the UK: Results of a Delphi study. Br J Clin Pharmacol 2021; 87:2879-2890. [PMID: 33300160 DOI: 10.1111/bcp.14698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 11/25/2020] [Accepted: 11/30/2020] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE To establish weight-based dose bands for commonly used oral medicines, given in liquid forms, for children in the UK that could be used for prescribing and administering accurate and safe drug doses. METHODS A list of commonly prescribed, oral liquid medications was established from the medication dispensing database of four UK hospitals and a primary care database. The evidence base of currently used dose regimens for each drug was identified from paediatric reference books, summary of product characteristics and the literature. Then, weight-based dose bands were developed and a modified Delphi process was used to achieve healthcare professional consensus about the suggested dose bands for each drug. RESULTS Forty-six experts in paediatric medicines participated in the Delphi process (mean years of experience 17.3 ± 9.4 [standard deviation]) and assessed 45 oral liquid drugs in total. Four categories of weight-based dose bands were established: drugs with two dose bands (17.8%, 8/45), drugs with three dose bands (64.4%, 29/45), drugs with four dose bands (15.6%, 7/45) and drugs with five dose bands (2.2%, 1/45). The 46 participants reached consensus on all the suggested dose bands for 53.3% (24/45) of the drugs. Consensus was reached in the first round of the Delphi process for 91.7% (22/24) of the drugs and after two rounds for two drugs. No agreement was achieved on any of the suggested dose bands for 26.7% (12/45) of the drugs. CONCLUSION This study provides healthcare professionals with a set of recommended weight-based dose bands for commonly prescribed oral liquid drugs for children. These bands could establish the basis for change in clinical practice to reduce dosing errors and improve healthcare for children.
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Affiliation(s)
- Asia N Rashed
- King's College London, Institute of Pharmaceutical Science, London, UK.,Guy's and St Thomas' NHS Foundation Trust, Evelina London Children's Hospital, Evelina Pharmacy, London, UK
| | - Stephen Tomlin
- Great Ormond Street Hospital for Children NHS Foundation Trust, Pharmacy Department, London, UK
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9
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Olakotan OO, Yusof MM. Evaluating the alert appropriateness of clinical decision support systems in supporting clinical workflow. J Biomed Inform 2020; 106:103453. [PMID: 32417444 DOI: 10.1016/j.jbi.2020.103453] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 05/08/2020] [Accepted: 05/09/2020] [Indexed: 02/06/2023]
Abstract
The overwhelming number of medication alerts generated by clinical decision support systems (CDSS) has led to inappropriate alert overrides, which may lead to unintended patient harm. This review highlights the factors affecting the alert appropriateness of CDSS and barriers to the fit of CDSS alert with clinical workflow. A literature review was conducted to identify features and functions pertinent to CDSS alert appropriateness using the five rights of CDSS. Moreover, a process improvement method, namely, Lean, was used as a tool to optimise clinical workflows, and the appropriate design for CDSS alert using a human automation interaction (HAI) model was recommended. Evaluating the appropriateness of CDSS alert and its impact on workflow provided insights into how alerts can be designed and triggered effectively to support clinical workflow. The application of Lean methods and tools to analyse alert efficiencies in supporting workflow in this study provides an in-depth understanding of alert-workflow fit problems and their root cause, which is required for improving CDSS design. The application of the HAI model is recommended in the design of CDSS alerts to support various levels and stages of alert automations, namely, information acquisition and analysis, decision action and action implementation.
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Affiliation(s)
| | - Maryati Mohd Yusof
- Faculty of Information Science & Technology, Universiti Kebangsaan Malaysia, Bangi, Selangor, Malaysia.
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10
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Fusco NM, Islam S, Polischuk E. Optimal Antibiotics at Hospital Discharge for Children With Urinary Tract Infection. Hosp Pediatr 2020; 10:438-442. [PMID: 32312729 DOI: 10.1542/hpeds.2019-0301] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Antibiotic stewardship at hospital discharge is an area of need. We assessed the rate of optimal antibiotic prescriptions at hospital discharge, on the basis of urine culture and susceptibility data, for children diagnosed with a urinary tract infection (UTI). METHODS We conducted a retrospective study of patients ≤18 years of age who were admitted to a general pediatrics service at a freestanding children's hospital during 2017 with a diagnosis of UTI and received an antibiotic prescription at discharge. For the primary analysis, optimal antibiotic at hospital discharge was determined by evaluating if the cultured urinary pathogen was susceptible to the prescribed antibiotic and if the antibiotic was the narrowest-spectrum option available. Secondary objectives included assessment of antibiotic dosing accuracy and description of antibiotic treatment duration. RESULTS A total of 78 cases were included. Sixty-eight (83%) cases were caused by cefazolin-susceptible Escherichia coli and Klebsiella species. Thirty-one (40%) cases had a discharge antibiotic prescription that was determined to be optimal. Of the 47 (60%) cases that were suboptimal, 44 (94%) were considered to be excessively broad spectrum. In 3 (6%) cases, the causative organism was nonsusceptible to the prescribed antibiotic. Ten (13%) discharge antibiotic prescriptions had inaccurate dosing and/or frequency. CONCLUSIONS Missed opportunities for narrow-spectrum antibiotic selection at hospital discharge for pediatric UTIs frequently occurred. In particular, higher-generation cephalosporins and ciprofloxacin were often prescribed for cephalexin-susceptible cases. Antibiotic stewardship attention, specifically at hospital discharge for pediatric UTIs, is likely to have a high impact.
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Affiliation(s)
- Nicholas M Fusco
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences and
| | - Shamim Islam
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York; and
| | - Emily Polischuk
- Department of Pharmacy, John R. Oishei Children's Hospital, Buffalo, New York
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11
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Shah S, Chui M. Addressing need and formulating ideas to mitigate prescribing errors in pediatric settings. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2019. [DOI: 10.1177/2516043519887051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Shweta Shah
- School of Pharmacy, University of Wisconsin-Madison, Madison, USA
| | - Michelle Chui
- School of Pharmacy, University of Wisconsin-Madison, Madison, USA
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12
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O'Mara K, Campbell C. Dosing inaccuracy with enteral use of ENFit ® low-dose tip syringes: The risk beyond oral adapters. J Clin Pharm Ther 2019; 45:335-339. [PMID: 31755574 DOI: 10.1111/jcpt.13079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/07/2019] [Accepted: 10/29/2019] [Indexed: 12/01/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE As the global adoption of ENFit-compatible syringes becomes more widespread, it is important for syringe users to understand the risk of dosing inaccuracy for both the oral and enteral routes of use. Describing the risk of dosing inaccuracy specifically related to route of use is important to the end users' understanding of the clinical impact of device changes. The objective of this study was to compare the performance of female design ENFit low dose tip (LDT) syringes when used for enteral medication administration to the syringe performance during oral administration conditions. METHODS This study was a secondary analysis of a prospective study conducted at the University of Florida Health Shands Hospital in conjunction with the University of Florida College of Pharmacy. Dosing variance (DV) up to 10% for low-risk medications and DV up to 5% is the target for high-risk medication administration is considered acceptable. The primary outcome was the frequency of administration volumes exceeding 10% of the expected amount when using the ENFit LDT syringe for both oral and enteral medication administration. Secondarily, the performance of standard ENFit syringes and the frequencies of DV exceeding 5 and 10% were also evaluated in the same conditions. RESULTS AND DISCUSSION A total of 264 tests were evaluated (ENFit LDT, n = 210; ENFit standard tip, n = 54). Using the LDT syringe for the enteral route resulted in statistically significant higher rates of unacceptable dosing variance >10% when compared to the oral application (26.9% vs 12.9%, P = .01). The frequency of LDT syringe DV >5% was significantly greater than >10% variance, regardless of oral or enteral use. Standard ENFit syringes had overall fewer tests with unacceptable dosing variance and showed no difference in performance between applications. WHAT IS NEW AND CONCLUSIONS This study raises additional clinical concerns specifically related to the enteral use of ENFit LDT syringes within commonly accepted dosing variance ranges. Enteral and oral application of LDT syringes yield unacceptably high rates of dosing variance for high risk medications with narrow therapeutic index.
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Affiliation(s)
| | - Christopher Campbell
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
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13
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Philips K, Zhou R, Lee DS, Marrese C, Nazif J, Browne C, Sinnett M, Tuckman S, Griffith K, Kiely V, Lutz M, Modi A, Rinke ML. Caregiver Medication Management and Understanding After Pediatric Hospital Discharge. Hosp Pediatr 2019; 9:844-850. [PMID: 31582401 PMCID: PMC6818354 DOI: 10.1542/hpeds.2019-0036] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Caregivers frequently make mistakes when following instructions on discharge medications, and these instructions often contain discrepancies. Minimal literature reflects inpatient discharges. Our objective was to describe failures in caregiver management and understanding of inpatient discharge medications and to test the association of documentation discrepancies and sociodemographic factors with medication-related failures after an inpatient hospitalization. METHODS This study took place in an urban tertiary care children's hospital that serves a low-income, minority population. English-speaking caregivers of children discharged on an oral prescription medication were surveyed about discharge medication knowledge 48 to 96 hours after discharge. The primary outcome was the proportion of caregivers who failed questions on a 10-item questionnaire (analyzed as individual question responses and as a composite outcome of any discharge medication-related failure). Bivariate tests were used to compare documentation errors, complex dosing, and sociodemographic factors to having any discharge medication-related failure. RESULTS Of 157 caregivers surveyed, 70% had a discharge medication-related failure, most commonly because of lack of knowledge about side effects (52%), wrong duration (17%), and wrong start time (16%). Additionally, 80% of discharge instructions provided to caregivers lacked integral medication information, such as duration or when the next dose after discharge was due. Twenty five percent of prescriptions contained numerically complex doses. In bivariate testing, only race and/or ethnicity was significantly associated with having any failure (P = .03). CONCLUSIONS The majority of caregivers had a medication-related failure after discharge, and most discharge instructions lacked key medication information. Future work to optimize the discharge process to support caregiver management and understanding of medications is needed.
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Affiliation(s)
- Kaitlyn Philips
- Children's Hospital at Montefiore, Bronx, New York;
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York; and
| | - Roy Zhou
- Children's Hospital at Montefiore, Bronx, New York
| | - Diana S Lee
- Children's Hospital at Montefiore, Bronx, New York
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York; and
| | | | - Joanne Nazif
- Children's Hospital at Montefiore, Bronx, New York
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York; and
| | | | - Mark Sinnett
- Children's Hospital at Montefiore, Bronx, New York
| | | | | | | | - Marcia Lutz
- Children's Hospital at Montefiore, Bronx, New York
| | - Anjali Modi
- Children's Hospital at Montefiore, Bronx, New York
| | - Michael L Rinke
- Children's Hospital at Montefiore, Bronx, New York
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York; and
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14
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O'Mara K, Gattoline SJ, Campbell CT. Female low dose tip syringes-increased complexity of use may compromise dosing accuracy in paediatric patients. J Clin Pharm Ther 2019; 44:463-470. [PMID: 30763471 DOI: 10.1111/jcpt.12810] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 12/28/2018] [Accepted: 01/10/2019] [Indexed: 11/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE The International Organization for Standardization (ISO) created enteral device specifications to reduce tubing misconnections. The Global Enteral Device Supplier Association (GEDSA) supports a female design: standard and low dose tip (LDT). Concerns include increased complexity of use with adapters, dosing accuracy and workflow. No peer-reviewed studies have evaluated dosing accuracy of the complete female system with adapters. The objective of this study was to compare dosing accuracy of the female design to legacy syringes. METHODS An in vitro study was conducted at the University of Florida College of Pharmacy pharmaceutics laboratory. Assessments were completed for syringe size, dispense methods and volumes, and adapters when applicable. A gravimetric scale and specific gravity were used to calculate administration volumes. The primary outcome was frequency administration volume exceeded 10% expected amount. RESULTS AND DISCUSSION A total of 576 tests were performed. The LDT resulted in significantly higher rates of unacceptable dosing variance compared to legacy (21.2% vs 7.4%, P = 0.003). Variance exceeding 10% occurred more frequently with LDT 0.5 and 1 mL syringes, medication cup dispensing (liquid or tablet) and inappropriate LDT adapter use. Unapproved adapter processes compared to FDA-approved processes held a higher likelihood of unacceptable dosing variance (28% vs 7.4%, P < 0.001). FDA-approved use of adapters with prefilled syringes compared to bedside administration may result in higher rates of dosing inaccuracy (18.8% vs 5.6%, P = 0.06). WHAT IS NEW AND CONCLUSIONS This study raises clinical concerns of dosing inaccuracies with the LDT syringes, particularly with 0.5 and 1 mL sizes. The use of adapters significantly increases the opportunity for inaccurate dosing.
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Affiliation(s)
- Keliana O'Mara
- Department of Pharmacy, UF Health Shands Children's Hospital, Newberry, Florida
| | | | - Christopher T Campbell
- Department of Pharmacy, UF Health Shands Children's Hospital, Newberry, Florida
- University of Florida College of Pharmacy, Gainesville, Florida
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15
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Rashed AN, Tomlin S, Arenas-López S, Cavell G, Whittlesea C. Evaluation of the practice of dose-rounding in paediatrics. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2019; 28:107-110. [DOI: 10.1111/ijpp.12549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 05/06/2019] [Indexed: 12/01/2022]
Abstract
Abstract
Objectives
To investigate the rounding of prescribed drug doses for paediatric administration.
Methods
A cross-sectional medication chart review was conducted at a UK paediatric hospital. Proposed administration dose volumes were calculated for prescribed doses using available manufactured liquids measured with oral and intravenous syringes. Resulting percentage deviations in doses administered were calculated.
Results
Of 2031 doses observed, 524 (25.8%) required rounding. The majority of which were for children aged 1–12 months. Twenty-seven rounded doses deviated from the prescribed dose by more than 10%.
Conclusion
This study highlights the impact of dose-rounding in paediatrics and the need for standardisation.
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Affiliation(s)
- Asia N Rashed
- Institute of Pharmaceutical Science, King’s College London, London, UK
- Pharmacy Department, Evelina London Children’s Hospital, Guy’s & St Thomas’ NHS Foundation Trust, London, UK
| | - Stephen Tomlin
- Institute of Pharmaceutical Science, King’s College London, London, UK
- Pharmacy Department, Evelina London Children’s Hospital, Guy’s & St Thomas’ NHS Foundation Trust, London, UK
| | - Sara Arenas-López
- Pharmacy Department, Evelina London Children’s Hospital, Guy’s & St Thomas’ NHS Foundation Trust, London, UK
| | - Gillian Cavell
- Pharmacy Department, King's College Hospital NHS Foundation Trust, London, UK
| | - Cate Whittlesea
- Research Department & Practice and Policy, UCL School of Pharmacy, London, UK
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16
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Fahey OG, Koth SM, Bergsbaken JJ, Jones HA, Trapskin PJ. Automated parenteral chemotherapy dose-banding to improve patient safety and decrease drug costs. J Oncol Pharm Pract 2019; 26:345-350. [PMID: 31046608 DOI: 10.1177/1078155219846958] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE To improve patient safety and reduce drug waste through implementation of automated parenteral chemotherapy dose-banding within an electronic health record. METHODS Parenteral chemotherapy dose-rounding practices were transitioned from a manual, pharmacist-driven workflow to an automated process within the electronic health record. Initial medications transitioned included bevacizumab, rituximab, and trastuzumab. Dose-banding tables were built to standardize rounding within a 10% parameter and then subsequently incorporated into the electronic health record after receiving multidisciplinary approval. Following implementation, a retrospective chart review was performed to compare drug and associated cost savings with manual dose-rounding and automated dose-banding. Medication safety improvements were measured by comparing the change in the number of clicks needed for pharmacist verification as well as by evaluation of submissions to our event reporting system. RESULTS After implementing automated parenteral chemotherapy dose-banding, reported medication errors associated with the parenteral chemotherapy rounding process decreased. The number of event submissions related to incorrect rounding decreased from four submissions in the pre-implementation period to zero in the post-implementation period. Automation saved pharmacists at least 9,297 additional clicks and 11,363 additional keystrokes and also led to notable increases in total drug savings as well as drug cost savings. CONCLUSION Overall safety of our parenteral chemotherapy ordering processes within our electronic health record was improved after the implementation of automated dose-banding. By standardizing the administered doses for three chemotherapy agents, we were also able to increase total drug savings and associated drug cost savings.
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Affiliation(s)
| | - Sara M Koth
- Department of Pharmacy, Oregon Health & Science University, Portland, Oregon
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17
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Evaluation of Harm Associated with High Dose-Range Clinical Decision Support Overrides in the Intensive Care Unit. Drug Saf 2018; 42:573-579. [DOI: 10.1007/s40264-018-0756-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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18
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Tolley CL, Slight SP, Husband AK, Watson N, Bates DW. Improving medication-related clinical decision support. Am J Health Syst Pharm 2018; 75:239-246. [PMID: 29436470 DOI: 10.2146/ajhp160830] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Current uses of medication-related clinical decision support (CDS) and recommendations for improving these systems are reviewed. SUMMARY Using a systematic approach, articles published from 2007 through 2014 were identified in MEDLINE and EMBASE using MeSH terms and keywords relating to the 5 basic medication-related CDS functionalities. A total of 156 full-text articles and 28 conference abstracts were reviewed across each of the 5 areas: drug-drug interaction (DDI) checks (n = 78), drug allergy checks (n = 20), drug dose support (n = 55), drug duplication checks (n = 11), and drug formulary support (n = 20). The success of medication-related CDS depends on users finding the alerts valuable and acting on the information received. Improving alert specificity and sensitivity is important for all domains. Tiering is important for improving the acceptance of DDI alerts. The ability to perform appropriate cross-sensitivity checks is key to producing appropriate drug allergy checks. Drug dosage alerts should be individualized and deliver practical recommendations. How the system is configured to identify certain drug duplications is important to prevent possible patient toxicity. Accurate knowledge databases are needed to produce relevant drug formulary alerts and encourage formulary adherence. Medication-related CDS is still relatively immature in some organizations and has substantial room for improvement. For example, decision support should consider more patient-specific factors, human factors principles should always be considered, and alert specificity must be improved in order to reduce alert fatigue. CONCLUSION Standardization, integration of patient-specific parameters, and consideration of human factors design principles are central to realizing the potential benefits of medication-related CDS.
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Affiliation(s)
- Clare L Tolley
- Institute of Health and Society, Sir James Spence Institute, Newcastle University, Newcastle upon Tyne, United Kingdom, United Kingdom
| | - Sarah P Slight
- School of Pharmacy, Newcastle Univesity, Newcastle upon Tyne, United Kingdom .,Center for Patient Safety Research and Practice, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Andrew K Husband
- School of Pharmacy, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Neil Watson
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - David W Bates
- Center for Patient Safety Research and Practice, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
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19
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Alrifai MW, Mulherin DP, Weinberg ST, Wang L, Lehmann CU. Parenteral Protein Decision Support System Improves Protein Delivery in Preterm Infants: A Randomized Clinical Trial. JPEN J Parenter Enteral Nutr 2018; 42:219-224. [PMID: 29505147 DOI: 10.1002/jpen.1034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 08/11/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Management of neonatal parenteral protein intake for preterm infants is challenging and requires daily modifications of the dose to account for the infant's postnatal age, birth weight, current weight, and the volume and protein concentration of concurrent enteral nutrition. The objective of this study was to create and evaluate the Parenteral Protein Calculator (PPC), a clinical decision support system to improve the accuracy of protein intake for preterm infants who require parenteral nutrition (PN). MATERIALS AND METHODS We integrated the PPC into the computerized provider order entry system and tested it in a randomized controlled trial (routine or PPC). Infants were eligible if they were ≤3 days old, had a birth weight ≤1500 g, and had no inborn error of metabolism. The primary outcome was the appropriate total protein intake, defined as target protein dose ±0.5 g/kg. RESULTS We randomly allocated 42 infants for 221 PN days in the control group and 211 in the PPC group. Total protein intake in the PPC group was more accurate as compared with the control group (appropriate protein dosing: odds ratio = 5.8; 95% CI, 2.7-12.4). Absolute deviation from protein target was 0.41 g/kg (0.24-0.58) lower in the PPC group. CONCLUSION The PPC improved appropriate protein dosing for premature infants receiving PN. Further studies are needed to test whether clinical decision support systems will reduce uremia and improve growth and to replicate similar findings in the cases of other PN nutrients.
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Affiliation(s)
- Mhd Wael Alrifai
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David P Mulherin
- HealthIT @VUMC, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stuart T Weinberg
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christoph U Lehmann
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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20
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Karande IS, Goff Z, Kewley J, Mehta S, Snelling T. Dose-Banding of Intravenous Piperacillin-Tazobactam in Pediatric Surgical Inpatients. J Pediatr Pharmacol Ther 2017; 22:364-368. [PMID: 29042838 DOI: 10.5863/1551-6776-22.5.364] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Antimicrobial doses in children are often prescribed by using an individually calculated dose per weight (e.g., mg/kg) or based on body surface area. Dosing errors are the most commonly reported medication errors in children. A "dose-banding" strategy is frequently used for some over-the-counter drugs to prevent dosing errors. It could also lead to efficiencies by enabling batch preparation of intravenous (IV) medications in hospitals. OBJECTIVES To evaluate whether use of dose-banding for IV piperacillin-tazobactam results in acceptable dose variation from standard practice of individualized prescription of 100 mg/kg in children. METHODS We conducted a historically controlled intervention study comparing prescriptions of IV piperacillin-tazobactam before vs. after introduction of dose-banding prescribing guidance for surgical inpatients weighing >5 kg and <16 years of age at the tertiary referral pediatric hospital in Western Australia. RESULTS Dose-banding of IV piperacillin-tazobactam (with a maximum of 15% departure from the recommended milligram-per-weight dose of 100 mg/kg) resulted in similar overall variation of prescribed dose in comparison to individualized milligram-per-weight (non-dose-banded) prescribing. There was a trend toward fewer prescriptions with large variance (>30% variation from the 100-mg/kg dose) in the dose-banded compared to the non-dose-banded group (1/140 vs. 5/105; p = 0.09). CONCLUSIONS Our study showed dose-banding of IV piperacillin-tazobactam resulted in acceptable variation when compared to individualized milligram-per-weight dosing in children. Prospectively designed controlled trials are warranted to determine whether dose-banding could reduce medication errors and optimize use of hospital resources. Implications for future practice could include faster batch preparation, shorter checking and dispensing time, and reduction in drug wastage.
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Affiliation(s)
- Indrajit S Karande
- Princess Margaret Hospital for Children (ISK, ZG, JK, TS), Perth, Australia, Fiona Stanley Hospital (SM), Perth, Australia, Telethon Kids Institute (SM), Perth, Australia, University of Notre Dame (SM), Fremantle, Australia, Wesfarmers Centre of Vaccines and Infectious Diseases (TS), Telethon Kids Institute, City, Country, and Menzies School of Health Research and Charles Darwin University (TS), Darwin, Australia
| | - Zoy Goff
- Princess Margaret Hospital for Children (ISK, ZG, JK, TS), Perth, Australia, Fiona Stanley Hospital (SM), Perth, Australia, Telethon Kids Institute (SM), Perth, Australia, University of Notre Dame (SM), Fremantle, Australia, Wesfarmers Centre of Vaccines and Infectious Diseases (TS), Telethon Kids Institute, City, Country, and Menzies School of Health Research and Charles Darwin University (TS), Darwin, Australia
| | - Jacqueline Kewley
- Princess Margaret Hospital for Children (ISK, ZG, JK, TS), Perth, Australia, Fiona Stanley Hospital (SM), Perth, Australia, Telethon Kids Institute (SM), Perth, Australia, University of Notre Dame (SM), Fremantle, Australia, Wesfarmers Centre of Vaccines and Infectious Diseases (TS), Telethon Kids Institute, City, Country, and Menzies School of Health Research and Charles Darwin University (TS), Darwin, Australia
| | - Shailender Mehta
- Princess Margaret Hospital for Children (ISK, ZG, JK, TS), Perth, Australia, Fiona Stanley Hospital (SM), Perth, Australia, Telethon Kids Institute (SM), Perth, Australia, University of Notre Dame (SM), Fremantle, Australia, Wesfarmers Centre of Vaccines and Infectious Diseases (TS), Telethon Kids Institute, City, Country, and Menzies School of Health Research and Charles Darwin University (TS), Darwin, Australia
| | - Thomas Snelling
- Princess Margaret Hospital for Children (ISK, ZG, JK, TS), Perth, Australia, Fiona Stanley Hospital (SM), Perth, Australia, Telethon Kids Institute (SM), Perth, Australia, University of Notre Dame (SM), Fremantle, Australia, Wesfarmers Centre of Vaccines and Infectious Diseases (TS), Telethon Kids Institute, City, Country, and Menzies School of Health Research and Charles Darwin University (TS), Darwin, Australia
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21
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Jones AN, Miller JL, Neely S, Ibach BW, Hagemann TM, Golding CL, Lewis TV, Peek LA, Johnson PN. Prevalence of Unrounded Medication Doses and Associated Factors Among Hospitalized Pediatric Patients. J Pediatr Pharmacol Ther 2017; 22:286-292. [PMID: 28943824 DOI: 10.5863/1551-6776-22.4.286] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES This study aims to determine the prevalence and factors associated with unrounded doses ordered via a computerized prescriber order entry (CPOE) system among children during a 1-week reference period. METHODS This retrospective, cross-sectional study included children younger than 18 years admitted during a 7-day period. An unrounded dose was defined as an unrounded actual dose (eg, dose calculated to the tenths place for non-neonatal intensive care (non-NICU) patients and dose calculated to the hundredth place for NICU patients) or unrounded volume per dose [eg, <0.1 mL for non-NICU patients and <0.01 mL for NICU patients]. A multilevel logistic regression model was used to determine the prevalence and factors associated with unrounded doses via a CPOE system with adjustment for clustering effects. RESULTS A total of 395 patients were admitted with 391 receiving medications. The overall prevalence of unrounded doses was 30% among the 2426 doses administered. Patients on the NICU team had the highest prevalence of unrounded doses. The odds of an unrounded dose were 4% (adjusted odds ratio, 0.96; 95% confidence interval, 0.94-0.98) lower with each additional kilogram increase in weight after controlling for age, route, scheduled versus as-needed administration, and cluster effects. CONCLUSIONS The prevalence of unrounded doses was higher than in previous studies. It was higher in smaller children after controlling for age, medication-related variables, and clustering. Future studies should focus on the role of CPOE in preventing unrounded and unmeasurable doses and if these strategies affect clinical outcomes (eg, adverse drug events).
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Abstract
BACKGROUND Cytokine modulators (adalimumab, infliximab, etanercept, anakinra, canakinumab, rituximab, tocilizumab and abatacept) are high-cost biologics used primarily in paediatrics to treat patients with juvenile idiopathic arthritis.1 Funding mechanisms are unreliable and inconsistent hence appropriate dose rounding is a key cost-saving measure.2 However, there is a lack of evidence-based guidance for dose rounding in paediatrics.3 AIMS AND OBJECTIVES: Determine if 100% of inpatient cytokine modulator prescriptions in rheumatology are dose rounded up or down to the nearest whole vial, pen or syringe if within 5 or 10% of the dose for patients less or more than 10 kg respectively.Establish financial impact of drug wastage due to failures in dose rounding. METHOD Retrospective data collection of electronic prescriptions for all cytokine modulators prescribed for rheumatology inpatients from January 2011 to December 2014. Prescriptions analysed using a five step process to determine if doses could have been rounded to nearest whole dose unit. Cost of waste resulting from failure to dose round also calculated. RESULTS Only 35% (380/1100) of prescriptions rounded to the nearest whole dose unit therefore audit standard not met. 97% (698/720) of all prescriptions not dose rounded were for tocilizumab and infliximab with approximate annual wastage of £11,000. Unexpected and significant unavoidable wastage identified due to lack of paediatric-friendly dose unit sizes, particularly for canakinumab (approximately £740,000/year). DISCUSSION Appropriate dose rounding does not appear to be common practice. Raising awareness and educating rheumatology and pharmacy teams as well as establishing local dose banding or rounding guidelines may improve future results. Tocilizumab is available in 80 mg, 200 mg and 400 mg vials therefore there is scope for flexibility in dose rounding if combinations are used appropriately. Unavoidable waste may be reduced through use of pharmacy central intravenous additive service (CIVAS) for preparation or use of biosimilars.
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Affiliation(s)
- Chris Paget
- Great Ormond Street Hospital for Children NHS Foundation Trust
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Challenges in pediatric drug use: A pharmacist point of view. Res Social Adm Pharm 2016; 13:653-655. [PMID: 27493130 DOI: 10.1016/j.sapharm.2016.06.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 06/30/2016] [Indexed: 11/20/2022]
Abstract
The pediatric population is an enormously diverse segment of population varying both in size and age. The diversity caused pharmacists face various challenges primarily related to procuring, provision as well as use of drugs in this group of patients. Pediatric dose calculation is particularly a concern for pharmacists. Another challenge faced by pharmacists is unavailability of suitable formulations for pediatric use. This has also led many pharmacists to prepare extemporaneous liquid preparations, even though stability data on such preparations are scarce. Some extemporaneous preparations contain excipients which are potentially harmful in children. Besides that, inadequate labeling and drug information for pediatric drug use had not only challenged pharmacists in recommending and optimizing drug use in children, but also inadvertently caused many drugs used outside the approved terms of the product license (off-label use). Pharmacists are striving to stay connected to overcome the common and comparable challenges faced in their day to day duties and strive to maximize the safe and effective use of medicines for children.
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Slight SP, Berner ES, Galanter W, Huff S, Lambert BL, Lannon C, Lehmann CU, McCourt BJ, McNamara M, Menachemi N, Payne TH, Spooner SA, Schiff GD, Wang TY, Akincigil A, Crystal S, Fortmann SP, Bates DW. Meaningful Use of Electronic Health Records: Experiences From the Field and Future Opportunities. JMIR Med Inform 2015; 3:e30. [PMID: 26385598 PMCID: PMC4704893 DOI: 10.2196/medinform.4457] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Revised: 06/02/2015] [Accepted: 07/24/2015] [Indexed: 11/20/2022] Open
Abstract
Background With the aim of improving health care processes through health information technology (HIT), the US government has promulgated requirements for “meaningful use” (MU) of electronic health records (EHRs) as a condition for providers receiving financial incentives for the adoption and use of these systems. Considerable uncertainty remains about the impact of these requirements on the effective application of EHR systems. Objective The Agency for Healthcare Research and Quality (AHRQ)-sponsored Centers for Education and Research in Therapeutics (CERTs) critically examined the impact of the MU policy relating to the use of medications and jointly developed recommendations to help inform future HIT policy. Methods We gathered perspectives from a wide range of stakeholders (N=35) who had experience with MU requirements, including academicians, practitioners, and policy makers from different health care organizations including and beyond the CERTs. Specific issues and recommendations were discussed and agreed on as a group. Results Stakeholders’ knowledge and experiences from implementing MU requirements fell into 6 domains: (1) accuracy of medication lists and medication reconciliation, (2) problem list accuracy and the shift in HIT priorities, (3) accuracy of allergy lists and allergy-related standards development, (4) support of safer and effective prescribing for children, (5) considerations for rural communities, and (6) general issues with achieving MU. Standards are needed to better facilitate the exchange of data elements between health care settings. Several organizations felt that their preoccupation with fulfilling MU requirements stifled innovation. Greater emphasis should be placed on local HIT configurations that better address population health care needs. Conclusions Although MU has stimulated adoption of EHRs, its effects on quality and safety remain uncertain. Stakeholders felt that MU requirements should be more flexible and recognize that integrated models may achieve information-sharing goals in alternate ways. Future certification rules and requirements should enhance EHR functionalities critical for safer prescribing of medications in children.
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Affiliation(s)
- Sarah Patricia Slight
- Division of Pharmacy, School of Medicine Pharmacy and Health, Durham University, Durham, United Kingdom
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Guérin A, Bussières JF, Boulkedid R, Bourdon O, Prot-Labarthe S. Development of a consensus-base list of criteria for prescribing medication in a pediatric population. Int J Clin Pharm 2015; 37:883-94. [PMID: 26017398 DOI: 10.1007/s11096-015-0139-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 05/19/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although many people are involved in the optimal use of a medication within this process, the use of medications carries risks of adverse events, which are greater in the pediatric population because of many factors. OBJECTIVE In this context, our aim was to develop a consensus-based list of criteria for the safety of the pediatric medication-use process or circuit (referred to from now on as the CIRCUS tool: CIRcuit-of-Child-drug-USe). SETTING Multicenter with a trio of experts from eight university hospitals. METHODS A literature search (1998-2013) was conducted in order to identify the different safety practice domains for the pediatric medication use process. Twenty-six safety practice domains were identified and 48 compliance criteria were formulated. In order to reach a consensus on the most relevant compliance criteria for safety practices, an international 24 French-speaking multidisciplinary panelists (8 doctors, 8 pharmacists and 8 nurses) selected to represent a broad range of experience levels and specialties took part in a two round Delphi survey which was conducted between March and July 2013. Each panelist was asked to rate each proposed criterion on a 1-9 Likert scale in order to show their level of agreement (i.e. 1 reflects strong disagreement and 9 reflects strong agreement). MAIN OUTCOME MEASURE Development of a consensus-base list for safety practices in pediatrics. RESULTS Twenty-two of the 24 professionals invited to take part in this survey (92% participation rate) completed the two Delphi rounds. At the end of the two Delphi rounds, a total of 38/48 (79%) safety practice compliance criteria achieved consensus by the panelists. The criteria were grouped into 23 domains. CONCLUSION This study presents the development of a self-assessment tool for safety practices in the pediatric drug-use process using a Delphi method. This tool may be used in order to record and compare the prevalence of best safety practices in the pediatric drug-use process.
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Affiliation(s)
- A Guérin
- Pharmacy Practice Research Unit, Pharmacy Department, Sainte-Justine University Health Center, 3175, chemin de la Côte Sainte-Catherine, Montreal, Quebec, H3T 1C5, Canada.
| | - J F Bussières
- Pharmacy Department, Sainte-Justine University Health Center, Montreal, Quebec, Canada
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada
| | - R Boulkedid
- Clinical Epidemiology Unit, APHP, Robert Debré University Health Center, 75019, Paris, France
- INSERM, U 1123 and CIC 1426, Robert Debré University Health Center, 75019, Paris, France
| | - O Bourdon
- Pharmacy Department, APHP, Robert Debré University Health Center, Paris, France
- Department of Clinical Pharmacy, Faculty of Pharmacy, Université Paris Descartes, Sorbonne Paris Cité, France
- Laboratory Education and Health Practices EA 3412, Université Paris 13, Sorbonne Paris Cité, France
- French Society of Clinical Pharmacy, Paris, France
| | - S Prot-Labarthe
- Pharmacy Department, APHP, Robert Debré University Health Center, Paris, France
- French Society of Clinical Pharmacy, Paris, France
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Robinson CA, Siu A, Meyers R, Lee BH, Cash J. Standard dose development for medications commonly used in the neonatal intensive care unit. J Pediatr Pharmacol Ther 2014; 19:118-26. [PMID: 25024672 DOI: 10.5863/1551-6776-19.2.118] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To establish standardized, rounded doses of medications for neonates in the neonatal intensive care unit (NICU) through a multi-institutional peer-reviewed process. METHODS Pediatric faculty and pediatric pharmacy residents from the Ernest Mario School of Pharmacy (Piscataway, NJ) conducted a systematic review of rounded, weight-based medication information for neonatal patients from September 2010 to April 2011. After initial review, an expanded workgroup of expert neonatal pharmacy clinicians from academic institutions throughout the United States were invited to conduct a final review. The workgroup identified 74 medications or indications in the NICU. Recommended standardized doses were established for discrete weight categories at workgroup consensus web meetings conducted from June to December 2011. Workgroup recommendations were cross-referenced with published neonatal pharmacology resources. Consensus was obtained when references provided insufficient information on medication information. RESULTS Seventeen weight categories of increasing ranges were used, from 40 g for the lowest weights (e.g., 410-450 g) to 840 g for the highest weights (e.g., 3660-4500 g). Medications were divided into 3 categories of administration routes: oral (n = 4), intermittent intravenous (n = 64), and other (e.g., intramuscular; n=6). A significant majority of standardized doses (84%) were within 15% of their corresponding weight-calculated dose. CONCLUSIONS Establishment of a portfolio of standardized, rounded doses of medications commonly used in the NICU was feasibly established by a multi-institutional peer review process, with the great majority of standardized doses being within clinically acceptable ranges of administration. Use of standardized, rounded doses for reduction in dosing errors may be feasible on a systematic level.
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Affiliation(s)
- Christine A Robinson
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, New Jersey ; Morristown Medical Center, Morristown, New Jersey
| | - Anita Siu
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, New Jersey ; Jersey Shore University Medical Center, Neptune, New Jersey
| | - Rachel Meyers
- Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, New Jersey ; Saint Barnabas Medical Center, Livingston, New Jersey
| | - Ben H Lee
- Morristown Medical Center, Morristown, New Jersey
| | - Jared Cash
- Primary Children's Hospital (Intermountain Healthcare), Salt Lake City, Utah
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Emmerson AJ, Roberts SA. Rounding of birth weights in a neonatal intensive care unit over 20 years: an analysis of a large cohort study. BMJ Open 2013; 3:e003650. [PMID: 24319272 PMCID: PMC3855566 DOI: 10.1136/bmjopen-2013-003650] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To determine the frequency of birth weight digit preference for infants admitted to a large neonatal intensive care unit (NICU), the scale of rounding and its dependence on birth weight, and time and the impact on prescribing accuracy. DESIGN A consecutive cohort of birth weights extracted retrospectively from a single clinical database. SETTING AND PARTICIPANTS Birth weights from 9170 inborn infants recorded on an electronic prescribing database admitted to NICU over 20 years. STATISTICAL APPROACH Data are presented for the frequency of each of the possible pairs of final digits. A statistical model of digit preference assuming rounding is used to quantify the proportions rounding to specific accuracy levels. These proportions are compared between those <1000 g and those above and over the 20-year time period. RESULTS From a population of 9170 infants admitted over 20 years, there was a highly statistically significant digit bias with an increased prevalence of multiples of 100 (p<0.0001), 50 (p=0.007), 20 (p<0.0001), 10 (p<0.0001), 5 (p<0.0001) and 2 (p=0.0005). There was clear evidence of a reduced 100 g digit bias for infants 500 and 1000 g (0%) compared with those between 1000 and 4500 g (3.7%). The maximum birth weight error due to digit bias for all infants was 5%. There was clear evidence of an improvement in accuracy over 20 years. CONCLUSIONS Digit bias in birth weights over 20 years in a tertiary NICU is highly significant at the 100, 50, 20, 10, 5 and 2-digit levels. There has been a substantial improvement in the accuracy of birth weight measurements over 20 years. The likely maximum error due to birth weight digit bias is 5% and is within an acceptable tolerance for drug dosing even at very low birth weights.
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Affiliation(s)
- Anthony J Emmerson
- Newborn Intensive Care Unit, St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre (MAHSC), Manchester, UK
| | - Stephen A Roberts
- Centre for Biostatistics, Institute of Population Health, University of Manchester, Manchester Academic Health Science Centre (MAHSC), Manchester, UK
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Watts RG, Parsons K. Chemotherapy medication errors in a pediatric cancer treatment center: prospective characterization of error types and frequency and development of a quality improvement initiative to lower the error rate. Pediatr Blood Cancer 2013; 60:1320-4. [PMID: 23519908 DOI: 10.1002/pbc.24514] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 02/05/2013] [Indexed: 11/10/2022]
Abstract
BACKGROUND Chemotherapy medication errors occur in all cancer treatment programs. Such errors have potential severe consequences: either enhanced toxicity or impaired disease control. Understanding and limiting chemotherapy errors are imperative. PROCEDURE A multi-disciplinary team developed and implemented a prospective pharmacy surveillance system of chemotherapy prescribing and administration errors from 2008 to 2011 at a Children's Oncology Group-affiliated, pediatric cancer treatment program. Every chemotherapy order was prospectively reviewed for errors at the time of order submission. All chemotherapy errors were graded using standard error severity codes. Error rates were calculated by number of patient encounters and chemotherapy doses dispensed. Process improvement was utilized to develop techniques to minimize errors with a goal of zero errors reaching the patient. RESULTS Over the duration of the study, more than 20,000 chemotherapy orders were reviewed. Error rates were low (6/1,000 patient encounters and 3.9/1,000 medications dispensed) at the start of the project and reduced by 50% to 3/1,000 patient encounters and 1.8/1,000 medications dispensed during the initiative. Error types included chemotherapy dosing or prescribing errors (42% of errors), treatment roadmap errors (26%), supportive care errors (15%), timing errors (12%), and pharmacy dispensing errors (4%). Ninety-two percent of errors were intercepted before reaching the patient. No error caused identified patient harm. Efforts to lower rates were successful but have not succeeded in preventing all errors. CONCLUSIONS Chemotherapy medication errors are possibly unavoidable, but can be minimized by thoughtful, multispecialty review of current policies and procedures. Pediatr Blood Cancer 2013;601320-1324. © 2013 Wiley Periodicals, Inc.
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Affiliation(s)
- Raymond G Watts
- Division of Pediatric Hematology-Oncology, University of Alabama, Birmingham, Alabama 35233, USA
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Errores en la preparación de fármacos intravenosos en una Unidad de Cuidados Intensivos Neonatal. Una potencial fuente de eventos adversos. An Pediatr (Barc) 2013. [DOI: 10.1016/j.anpedi.2012.09.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Stultz JS, Nahata MC. Appropriateness of commercially available and partially customized medication dosing alerts among pediatric patients. J Am Med Inform Assoc 2013; 21:e35-42. [PMID: 23813540 DOI: 10.1136/amiajnl-2013-001725] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES To evaluate dosing alert appropriateness, categorize orders with alerts, and compare the appropriateness of alerts due to customized and non-customized dose ranges at a pediatric hospital. METHODS This was a retrospective analysis of medication orders causing dosing alerts. Orders for outpatient prescriptions, patients ≥18 years of age, and research protocols were excluded. Patient medical records were reviewed and ordered doses compared with a widely used pediatric reference (Lexi-Comp) and institutional recommendations. The alerted orders were categorized and the occurrence of appropriate alerts was compared. RESULTS There were 47 181 inpatient orders during the studied period; 1935 orders caused 3774 dosing alerts for 369 medications in 573 patients (median age 6.1 years). All alerted orders had an alert overridden by the prescriber. The majority (86.2%) of alerted orders inappropriately caused alerts; 58.0% were justifiable doses and 28.2% were within Lexi-Comp. However, 13.8% of alerted orders appropriately caused alerts; 8.0% were incorrect doses and 5.8% had no dosing recommendations available. Appropriately alerted orders occurred in 19.7% of alerted orders due to customized ranges compared to 12.8% due to non-customized ranges (p=0.002). Preterm and term neonates, infants, and children (2-5 years) had higher proportions of inappropriate alerts compared to appropriate alerts (all p<0.01). CONCLUSIONS The vast majority of dosing alerts were presented to practitioners inappropriately, potentially contributing to alert fatigue. Appropriate alerts occurred more often when alerts were due to customized ranges. Advances in dosing alerts should aim to provide accurate and clinically relevant alerts that minimize excessive inappropriate alerting. Medications requiring dosing adjustments based on clinical parameters must be taken into account when designing and evaluating dosing alerts.
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Affiliation(s)
- Jeremy S Stultz
- Nationwide Children's Hospital, Department of Pharmacy, Ohio State University College of Pharmacy, Columbus, Ohio, USA
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Johnson KB, Ho YX, Andrew Spooner S, Palmer M, Weinberg ST. Assessing the reliability of an automated dose-rounding algorithm. J Biomed Inform 2013; 46:814-21. [PMID: 23792464 DOI: 10.1016/j.jbi.2013.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2012] [Revised: 04/23/2013] [Accepted: 06/05/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Pediatric dose rounding is a unique and complex process whose complexity is rarely supported by e-prescribing systems, though amenable to automation and deployment from a central service provider. The goal of this project was to validate an automated dose-rounding algorithm for pediatric dose rounding. METHODS We developed a dose-rounding algorithm, STEPSTools, based on expert consensus about the rounding process and knowledge about the therapeutic/toxic window for each medication. We then used a 60% subsample of electronically-generated prescriptions from one academic medical center to further refine the web services. Once all issues were resolved, we used the remaining 40% of the prescriptions as a test sample and assessed the degree of concordance between automatically calculated optimal doses and the doses in the test sample. Cases with discrepant doses were compiled in a survey and assessed by pediatricians from two academic centers. The response rate for the survey was 25%. RESULTS Seventy-nine test cases were tested for concordance. For 20 cases, STEPSTools was unable to provide a recommended dose. The dose recommendation provided by STEPSTools was identical to that of the test prescription for 31 cases. For 14 out of the 24 discrepant cases included in the survey, respondents significantly preferred STEPSTools recommendations (p<0.05, binomial test). Overall, when combined with the data from all test cases, STEPSTools either matched or exceeded the performance of the test cases in 45/59 (76%) of the cases. The majority of other cases were challenged by the need to provide an extremely small dose. We estimated that with the addition of two dose-selection rules, STEPSTools would achieve an overall performance of 82% or higher. CONCLUSIONS Results of this pilot study suggest that automated dose rounding is a feasible mechanism for providing guidance to e-prescribing systems. These results also demonstrate the need for validating decision-support systems to support targeted and iterative improvement in performance.
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Affiliation(s)
- Kevin B Johnson
- Biomedical Informatics, Pediatrics, Vanderbilt University School of Medicine, 2209 Garland Ave, Room 428, Nashville, TN 37232, United States.
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Enhancing electronic health record usability in pediatric patient care: a scenario-based approach. Jt Comm J Qual Patient Saf 2013; 39:129-35. [PMID: 23516763 DOI: 10.1016/s1553-7250(13)39019-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Usability of electronic health records (EHRs) is an important factor affecting patient safety and the EHR adoption rate for both adult and pediatric care providers. A panel of interdisciplinary experts (the authors) was convened by the National Institute of Standards and Technology to generate consensus recommendations to improve EHR usefulness, usability, and patient safety when supporting pediatric care, with a focus on critical user interactions. METHODS The panel members represented expertise in the disciplines of human factors engineering (HFE), usability, informatics, and pediatrics in ambulatory care and pediatric intensive care. An iterative, scenario-based approach was used to identify unique considerations in pediatric care and relevant human factors concepts. A draft of the recommendations were reviewed by invited experts in pediatric informatics, emergency medicine, neonatology, pediatrics, HFE, nursing, usability engineering, and software development and implementation. RECOMMENDATIONS Recommendations for EHR developers, small-group pediatric medical practices, and children's hospitals were identified out of the original 54 recommendations, in terms of nine critical user interaction categories: patient identification, medications, alerts, growth chart, vaccinations, labs, newborn care, privacy, and radiology. CONCLUSION Pediatric patient care has unique dimensions, with great complexity and high stakes for adverse events. The recommendations are anticipated to increase the rate of EHR adoption by pediatric care providers and improve patient safety for pediatric patients. The described methodology might be useful for accelerating adoption and increasing safety in a variety of clinical areas where the adoption of EHRs is lagging or usability issues are believed to reduce potential patient safety, efficiency, and quality benefits.
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Jarkowski A, Nestico JS, Vona KL, Khushalani NI. Dose rounding of ipilimumab in adult metastatic melanoma patients results in significant cost savings. J Oncol Pharm Pract 2013; 20:47-50. [DOI: 10.1177/1078155213476723] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose To assess cost savings incurred with a dose rounding process that was implemented for ipilimumab. Secondarily, to assess response rates, patient tolerance, and adverse effects associated with ipilimumab upon implementation of dose rounding. Methods All patients with a diagnosis of metastatic melanoma and who received at least one dose ipilimumab were included for analysis. Doses of ipilimumab were calculated based upon the actual body weight (in kg) of the patient at the FDA approved regimen of 3 mg/kg every 21 days × 4 doses. The exact total mg dose was then rounded to the nearest 50 mg vial size. The potential effect on cost was calculated in US dollars for both the calculated and rounded doses. Waste, in mg, was defined as the amount of drug that may have been discarded if the calculated dose was used for therapy. The acquisition cost applied was US$120 per mg. Results 22 patients have received at least one dose of ipilimumab. 11 patients have completed therapy and received all four induction doses. 9 patients discontinued therapy early and 2 patients were still actively receiving induction at the time of this analysis. A total of 63 doses were given. The maximum potential cost savings by giving ipilimumab to the nearest 50 mg over the period was 155,400. Conclusions Dose rounding of ipilimumab to the nearest 50 mg has the potential to result in a significant cost savings by eliminating drug waste.
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Affiliation(s)
- Anthony Jarkowski
- James P Wilmot Cancer Center at the University of Rochester Medical Center, Rochester, NY, USA
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Spooner SA. We are still waiting for fully supportive electronic health records in pediatrics. Pediatrics 2012; 130:e1674-6. [PMID: 23166347 DOI: 10.1542/peds.2012-2724] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- S Andrew Spooner
- Cincinnati Children’s Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45229.
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Stultz JS, Nahata MC. Computerized clinical decision support for medication prescribing and utilization in pediatrics. J Am Med Inform Assoc 2012; 19:942-53. [PMID: 22813761 PMCID: PMC3534459 DOI: 10.1136/amiajnl-2011-000798] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 06/26/2012] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Accurate and informed prescribing is essential to ensure the safe and effective use of medications in pediatric patients. Computerized clinical decision support (CCDS) functionalities have been embedded into computerized physician order entry systems with the aim of ensuring accurate and informed medication prescribing. Owing to a lack of comprehensive analysis of the existing literature, this review was undertaken to analyze the effect of CCDS implementation on medication prescribing and use in pediatrics. MATERIALS AND METHODS A literature search was performed using keywords in PubMed to identify research studies with outcomes related to the implementation of medication-related CCDS functionalities. RESULTS AND DISCUSSION Various CCDS functionalities have been implemented in pediatric patients leading to different results. Medication dosing calculators have decreased calculation errors. Alert-based CCDS functionalities, such as duplicate therapy and medication allergy checking, may generate excessive alerts. Medication interaction CCDS has been minimally studied in pediatrics. Medication dosing support has decreased adverse drug events, but has also been associated with high override rates. Use of medication order sets have improved guideline adherence. Guideline-based treatment recommendations generated by CCDS functionalities have had variable influence on appropriate medication use, with few studies available demonstrating improved patient outcomes due to CCDS use. CONCLUSION Although certain medication-related CCDS functionalities have shown benefit in medication prescribing for pediatric patients, others have resulted in high override rates and inconsistent or unknown impact on patient care. Further studies analyzing the effect of individual CCDS functionalities on safe and effective prescribing and medication use are required.
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Affiliation(s)
- Jeremy S Stultz
- Ohio State University College of Pharmacy, Columbus, Ohio, USA
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