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A framework for evaluating the appropriateness of clinical decision support alerts and responses.
McCoy AB, Waitman LR, Lewis JB, Wright JA, Choma DP, Miller RA, Peterson JF
(2012) J Am Med Inform Assoc 19: 346-52
MeSH Terms: Acute Kidney Injury, Decision Support Systems, Clinical, Drug Therapy, Computer-Assisted, Electronic Health Records, Humans, Medical Audit, Medical Order Entry Systems, Medication Errors, Medication Systems, Hospital, Models, Theoretical, Reminder Systems, Retrospective Studies, Single-Blind Method, Tennessee, User-Computer Interface
Show Abstract · Added December 10, 2013
OBJECTIVE - Alerting systems, a type of clinical decision support, are increasingly prevalent in healthcare, yet few studies have concurrently measured the appropriateness of alerts with provider responses to alerts. Recent reports of suboptimal alert system design and implementation highlight the need for better evaluation to inform future designs. The authors present a comprehensive framework for evaluating the clinical appropriateness of synchronous, interruptive medication safety alerts.
METHODS - Through literature review and iterative testing, metrics were developed that describe successes, justifiable overrides, provider non-adherence, and unintended adverse consequences of clinical decision support alerts. The framework was validated by applying it to a medication alerting system for patients with acute kidney injury (AKI).
RESULTS - Through expert review, the framework assesses each alert episode for appropriateness of the alert display and the necessity and urgency of a clinical response. Primary outcomes of the framework include the false positive alert rate, alert override rate, provider non-adherence rate, and rate of provider response appropriateness. Application of the framework to evaluate an existing AKI medication alerting system provided a more complete understanding of the process outcomes measured in the AKI medication alerting system. The authors confirmed that previous alerts and provider responses were most often appropriate.
CONCLUSION - The new evaluation model offers a potentially effective method for assessing the clinical appropriateness of synchronous interruptive medication alerts prior to evaluating patient outcomes in a comparative trial. More work can determine the generalizability of the framework for use in other settings and other alert types.
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15 MeSH Terms
Adopting real-time surveillance dashboards as a component of an enterprisewide medication safety strategy.
Waitman LR, Phillips IE, McCoy AB, Danciu I, Halpenny RM, Nelsen CL, Johnson DC, Starmer JM, Peterson JF
(2011) Jt Comm J Qual Patient Saf 37: 326-32
MeSH Terms: Aminoglycosides, Anticoagulants, Communication, Decision Support Systems, Clinical, Humans, Medical Records Systems, Computerized, Medication Errors, Pharmacy Service, Hospital, Safety Management
Show Abstract · Added May 19, 2014
BACKGROUND - High-alert medications are frequently responsible for adverse drug events and present significant hazards to inpatients, despite technical improvements in the way they are ordered, dispensed, and administered.
METHODS - A real-time surveillance application was designed and implemented to enable pharmacy review of high-alert medication orders to complement existing computerized provider order entry and integrated clinical decision support systems in a tertiary care hospital. The surveillance tool integrated real-time data from multiple clinical systems and applied logical criteria to highlight potentially high-risk scenarios. Use of the surveillance system for adult inpatients was analyzed for warfarin, heparin and enoxaparin, and aminoglycoside antibiotics.
RESULTS - Among 28,929 hospitalizations during the study period, patients eligible to appear on a dashboard included 2224 exposed to warfarin, 8383 to heparin or enoxaparin, and 893 to aminoglycosides. Clinical pharmacists reviewed the warfarin and aminoglycoside dashboards during 100% of the days in the study period-and the heparinlenoxaparin dashboard during 71% of the days. Displayed alert conditions ranged from common events, such as 55% of patients receiving aminoglycosides were missing a baseline creatinine, to rare events, such as 0.1% of patients exposed to heparin were given a bolus greater than 10,000 units. On the basis of interpharmacist communication and electronic medical record notes recorded within the dashboards, interventions to prevent further patient harm were frequent.
CONCLUSIONS - Even in an environment with sophisticated computerized provider order entry and clinical decision support systems, real-time pharmacy surveillance of high-alert medications provides an important platform for intercepting medication errors and optimizing therapy.
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9 MeSH Terms
Automated dose-rounding recommendations for pediatric medications.
Johnson KB, Lee CK, Spooner SA, Davison CL, Helmke JS, Weinberg ST
(2011) Pediatrics 128: e422-8
MeSH Terms: Child, Dose-Response Relationship, Drug, Drug Therapy, Computer-Assisted, Drug-Related Side Effects and Adverse Reactions, Electronic Prescribing, Health Care Surveys, Humans, Medical Order Entry Systems, Medication Errors, Pediatrics, Pharmaceutical Preparations
Show Abstract · Added February 12, 2015
BACKGROUND - Although pediatric electronic prescribing systems are increasingly being used in pediatric care, many of these systems lack the clinical decision-support infrastructure needed to calculate a safe and effective rounded medication dose. This infrastructure is required to facilitate tailoring of established dosing guidance while maintaining the medication's therapeutic intent.
OBJECTIVE - The goal of this project was to establish best practices for generating an appropriate medication dose and to create an interoperable rounding knowledge base combining best practices and dose-rounding information.
METHODS - We interviewed 19 pediatric health care and pediatric pharmacy experts and conducted a literature review. After using these data to construct initial rounding tolerances, we used a Delphi process to achieve consensus about the rounding tolerance for each commonly prescribed medication.
RESULTS - Three categories for medication-rounding philosophy emerged from our literature review: (1) medications for which rounding is used judiciously to retain the intended effect; (2) medications that are rounded with attention to potential unintended effects; and (3) medications that are rarely rounded because of the potential for toxicity. We assigned a small subset of medications to a fourth category-inadequate data-for which there was insufficient information to provide rounding recommendations. For all 102 medications, we were able to arrive at a consensus recommendation for rounding a given calculated dose.
CONCLUSIONS - Results of this study provide the pediatric information technology community with a primary set of recommended rounding tolerances for commonly prescribed drugs. The interoperable knowledge base developed here can be integrated with existing and developing electronic prescribing systems, potentially improving prescribing safety and reducing cognitive workload.
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11 MeSH Terms
Inappropriate medications in elderly ICU survivors: where to intervene?
Morandi A, Vasilevskis EE, Pandharipande PP, Girard TD, Solberg LM, Neal EB, Koestner T, Torres R, Thompson JL, Shintani AK, Han JH, Schnelle J, Fick DM, Ely EW, Kripalani S
(2011) Arch Intern Med 171: 1032-4
MeSH Terms: Aged, Aged, 80 and over, Drug-Related Side Effects and Adverse Reactions, Humans, Inappropriate Prescribing, Intensive Care Units, Male, Medication Errors, Patient Discharge, Pharmaceutical Preparations, Polypharmacy, Prospective Studies, Risk, Severity of Illness Index, Statistics, Nonparametric
Added May 27, 2014
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15 MeSH Terms
Prevalence and Clinical Significance of Discrepancies within Three Computerized Pre-Admission Medication Lists.
Peterson JF, Shi Y, Denny JC, Matheny ME, Schildcrout JS, Waitman LR, Miller RA
(2010) AMIA Annu Symp Proc 2010: 642-6
MeSH Terms: Hospitalization, Humans, Medication Errors, Medication Reconciliation, Patient Admission, Prevalence
Show Abstract · Added May 19, 2014
Inaccurate records of pre-admission medication exposure have been identified as a major source of medication error. Authors collected records of patients' pre-admission medications: 1) the most recent outpatient medication list ("EMR"), 2) the medication list recorded by admitting providers ("H&P"), and 3) a list generated by a medication reconciliation process conducted by nursing staff ("PAML"). Forty-eight sets of pre-admission records composed of 1087 medication entries were compared to a reference standard generated by trained study staff conducting an independent interview. Sensitivity was greatest for PAML (85%), compared to EMR (76%) and H&P (76%) sources. However, positive predictive value was greatest for the H&P source at 96% vs 88% and 91% for PAML and EMR sources respectively. Potentially harmful medication discrepancies were found within all lists. The authors concluded no single list was sufficiently accurate to avoid serious medication errors.
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6 MeSH Terms
What can paper-based clinical information systems tell us about the design of computerized clinical information systems (CIS) in the ICU?
Miller A, Pilcher D, Mercaldo N, Leong T, Scheinkestel C, Schildcrout J
(2010) Aust Crit Care 23: 130-40
MeSH Terms: Artifacts, Chi-Square Distribution, Decision Making, Equipment Design, Humans, Intensive Care Units, Interdisciplinary Communication, Medical Records Systems, Computerized, Medication Errors, Medication Systems, Hospital, Paper, Poisson Distribution, User-Computer Interface
Show Abstract · Added May 27, 2014
BACKGROUND - Screen designs in computerized clinical information systems (CIS) have been modeled on their paper predecessors. However, limited understanding about how paper forms support clinical work means that we risk repeating old mistakes and creating new opportunities for error and inefficiency as illustrated by problems associated with computerized provider order entry systems.
PURPOSE - This study was designed to elucidate principles underlying a successful ICU paper-based CIS. The research was guided by two exploratory hypotheses: (1) paper-based artefacts (charts, notes, equipment, order forms) are used differently by nurses, doctors and other healthcare professionals in different (formal and informal) conversation contexts and (2) different artefacts support different decision processes that are distributed across role-based conversations.
METHOD - All conversations undertaken at the bedsides of five patients were recorded with any supporting artefacts for five days per patient. Data was coded according to conversational role-holders, clinical decision process, conversational context and artefacts. 2133 data points were analyzed using Poisson logistic regression analyses.
RESULTS - Results show significant interactions between artefacts used during different professional conversations in different contexts (chi(2)((df=16))=55.8, p<0.0001). The interaction between artefacts used during different professional conversations for different clinical decision processes was not statistically significant although all two-way interactions were statistically significant.
CONCLUSIONS - Paper-based CIS have evolved to support complex interdisciplinary decision processes. The translation of two design principles - support interdisciplinary perspectives and integrate decision processes - from paper to computerized CIS may minimize the risks associated with computerization.
2010 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.
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13 MeSH Terms
Health literacy and quality: focus on chronic illness care and patient safety.
Rothman RL, Yin HS, Mulvaney S, Co JP, Homer C, Lannon C
(2009) Pediatrics 124 Suppl 3: S315-26
MeSH Terms: Adult, Age Factors, Child, Chronic Disease, Communication Barriers, Comprehension, Educational Status, Health Education, Health Knowledge, Attitudes, Practice, Health Status Disparities, Humans, Medical Errors, Medication Errors, Patient Education as Topic, Patient Participation, Patient-Centered Care, Quality Assurance, Health Care, Treatment Outcome, United States
Show Abstract · Added December 10, 2013
Despite a heightened focus on improving quality, recent studies have suggested that children only receive half of the indicated preventive, acute, or chronic care. Two major areas in need of improvement are chronic illness care and prevention of medical errors. Recently, health literacy has been identified as an important and potentially ameliorable factor for improving quality of care. Studies of adults have documented that lower health literacy is independently associated with poorer understanding of prescriptions and other medical information and worse chronic disease knowledge, self-management behaviors, and clinical outcomes. There is also growing evidence to suggest that health literacy is important in pediatric safety and chronic illness care. Adult studies have suggested that addressing literacy can lead to improved patient knowledge, behaviors, and outcomes. Early studies in the field of pediatrics have shown similar promise. There are significant opportunities to evaluate and demonstrate the importance of health literacy in improving pediatric quality of care. Efforts to address health literacy should be made to apply the 6 Institute of Medicine aims for quality-care that is safe, effective, patient centered, timely, efficient, and equitable. Efforts should also be made to consider the distinct nature of pediatric care and address the "4 D's" unique to child health: the developmental change of children over time; dependency on parents or adults; differential epidemiology of child health; and the different demographic patterns of children and their families.
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19 MeSH Terms
A system to improve medication safety in the setting of acute kidney injury: initial provider response.
McCoy AB, McCoy AB, Peterson JF, Gadd CS, Gadd C, Danciu I, Waitman LR
(2008) AMIA Annu Symp Proc : 1051
MeSH Terms: Acute Kidney Injury, Artificial Intelligence, Decision Support Systems, Clinical, Humans, Medical Records Systems, Computerized, Medication Errors, Tennessee
Show Abstract · Added January 20, 2015
Clinical decision support systems can decrease common errors related to inappropriate or excessive dosing for nephrotoxic or renally cleared drugs. We developed a comprehensive medication safety intervention with varying levels of workflow intrusiveness within computerized provider order entry to continuously monitor for and alert providers about early-onset acute kidney injury. Initial provider response to the interventions shows potential success in improving medication safety and suggests future enhancements to increase effectiveness.
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1 Members
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7 MeSH Terms
Medication administration discrepancies persist despite electronic ordering.
FitzHenry F, Peterson JF, Arrieta M, Waitman LR, Schildcrout JS, Miller RA
(2007) J Am Med Inform Assoc 14: 756-64
MeSH Terms: Adult, Aged, Angiotensin-Converting Enzyme Inhibitors, Anti-Arrhythmia Agents, Anti-Inflammatory Agents, Non-Steroidal, Diuretics, Drug Administration Schedule, Humans, Medical Audit, Medical Order Entry Systems, Medication Errors, Medication Systems, Hospital, Middle Aged, Outcome Assessment, Health Care, Quality Control, Retrospective Studies, Time Factors
Show Abstract · Added May 27, 2014
Background Up to 38% of inpatient medication errors occur at the administration stage. Although they reduce prescribing errors, computerized provider order entry (CPOE) systems do not prevent administration errors or timing discrepancies. This study determined the degree to which CPOE medication orders matched actual dose administration times. METHODS At a 658-bed academic hospital with CPOE but lacking electronic medication administration charting, authors randomly selected adult patients with eligible medication orders from historical 1999-2003 CPOE log files. Retrospective manual chart audits compared expected (from CPOE) and actual timing of medication administrations. Outcomes included: dose omissions, median lag times between ordered and charted administrations, unauthorized doses, wrong dose errors, and the rate of nurses' medication schedule shifting. RESULTS Dose omissions occurred in 756 of 6019 (12.6%) audited administration opportunities; only 313 of the omissions (5.2% of opportunities) were unexplained. Wrong doses and unexpected doses occurred for 0.1% and 0.7% of opportunities, respectively. Median lag from expected first dose to actual charted administration time was 27 minutes (IQR 0-127). Nursing staff shifted from ordered to alternate administration schedules for 10.7% of regularly scheduled recurring medication orders. Chart review identified reasons for dose omissions, delays, and dose shifting. CONCLUSION Inpatient CPOE orders are legible and conveyed electronically to nurses and the pharmacy. Nonetheless, ward-based medication administrations do not consistently occur as ordered. Medication administration discrepancies are likely to persist even after implementing CPOE and bar-coded medication administration unless recommended interventions are made to address issues such as determining the true urgency of medication administration, avoiding overlapping duplicative medication orders, and developing a safe means for shifting dosing schedules.
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17 MeSH Terms
Assessment of adverse drug events among patients in a tertiary care medical center.
Johnston PE, France DJ, Byrne DW, Murff HJ, Lee B, Stiles RA, Speroff T
(2006) Am J Health Syst Pharm 63: 2218-27
MeSH Terms: Academic Medical Centers, Adolescent, Adult, Adverse Drug Reaction Reporting Systems, Age Distribution, Age Factors, Aging, Child, Child, Preschool, Drug-Related Side Effects and Adverse Reactions, Female, Humans, Infant, Insurance, Health, Logistic Models, Male, Medication Errors, Middle Aged, Patient Admission, Reproducibility of Results, Risk Assessment, Risk Factors, Sex Characteristics, Sex Distribution, Sex Factors, United States
Show Abstract · Added March 5, 2014
PURPOSE - Specific patient and clinical characteristics associated with an increased risk of sustaining an adverse event (AE) were identified.
METHODS - AE reports for patients in a 658-bed tertiary care medical center between January 1, 2000, and June 30, 2002, were analyzed. The data collected from each report included medical record number, patient sex, patient age, clinical service, date of occurrence, diagnoses, type of error, suspected medication, and severity of the AE. A three-stage logistic regression model with high-risk indicators was used to evaluate key indicators of the most vulnerable patient populations.
RESULTS - The number of control patients and those with AEs totaled 60,206. This population was then randomly split into two equal groups of patients: the training data set (n = 30,103) and the validation data set (n = 30,103). AEs occurred in a higher percentage of patients who were age <1 year, 1-15, 47-59, and > or =60 years than in other groups. A higher percentage of AEs were reported in men than women, but the groups were not significantly different when comparing those with an AE and those without an AE. Asian Indian patients demonstrated a high rate of AEs, but this may be a statistical artifact, reflecting their very small percentage in the study. Evaluation of admission sources revealed that doctors' offices, clinic referrals, and local hospital transfers accounted for higher rates of AEs than other sources.
CONCLUSION - Certain age groups, diagnoses, admission sources, types of insurance, and the use of specific medications or medication classes were associated with increased AE rates at a tertiary care medical center.
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26 MeSH Terms