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PubMed2006

[Deployment of a computerized physician order entry: description of the process and challenges].

The introduction of a system of computerized physician order entry (CPOE) decreases medication error rates by formalizing the drafting of the orders and providing alarms which announce potential side effects, drug interactions and overly high doses. The quality of the CPOE does not insure its success. Its deployment must be preceded by an assessment and update of the available computer resources, by training of the users and setting up a help-desk attainable 24 hours a day. The project must be lead by senior medical and nursing staff. A joint effort is the key to ensure the success of CPOE and facilitate its acceptability. CPOE provides opportunities for improving: patient safety, training of professionals, quality and efficiency of care. CPOE systems are an ideal basis to set up clinical protocols and clinical pathways.

Medical Order Entry Systems↗
PubMed2006

[Electronic prescriptions--without side-effects?].

BACKGROUND: In a government document published in 2005, electronic information systems were held up as important tools for reducing unintended adverse drug events. The Norwegian Social and Health Directorate has now initiated a large national project introducing electronic prescribing. MATERIAL AND METHODS: We have analysed recent international literature about electronic prescribing and computerised physician order entry. RESULTS: Electronic information systems may cause both a reduction and an increase in adverse drug events. Certain known errors disappear, but new risks for errors are introduced. A new system might change or unintentionally put aside well-established safety routines in manual systems of today. INTERPRETATION: Introduction of electronic treatment of drug information can give many benefits, but if the risks for introducing new errors are underestimated, patient safety might be threatened. A strategy for avoiding possible mistakes should therefore be developed simultaneously with introduction of systems for electronic prescribing and order entry. New systems have to be thoroughly tested and evaluated as closely as other new technology and drugs when implemented.

Cost Savings↗
PubMed2006

Practitioners' views on computerized drug-drug interaction alerts in the VA system.

OBJECTIVES: To assess Veterans Affairs (VA) prescribers' and pharmacists' opinions about computer-generated drug-drug interaction (DDI) alerts and obtain suggestions for improving DDI alerts. DESIGN: A mail survey of 725 prescribers and 142 pharmacists from seven VA medical centers across the United States. MEASUREMENTS: A questionnaire asked respondents about their sources of drug and DDI information, satisfaction with the combined inpatient and outpatient computerized prescriber order entry (CPOE) system, attitude toward DDI alerts, and suggestions for improving DDI alerts. RESULTS: The overall response rate was 40% (prescribers: 36%; pharmacists: 59%). Both prescribers and pharmacists indicated that the CPOE system had a neutral to positive impact on their jobs. DDI alerts were not viewed as a waste of time and the majority (61%) of prescribers felt that DDI alerts had increased their potential to prescribe safely. However, only 30% of prescribers felt DDI alerts provided them with what they needed most of the time. Both prescribers and pharmacists agreed that DDI alerts should be accompanied by management alternatives (73% and 82%, respectively) and more detailed information (65% and 89%, respectively). When asked about suggestions for improving DDI alerts, prescribers most preferred including management options whereas pharmacists most preferred making it more difficult to override lethal interactions. Prescribers and pharmacists reported primarily relying on electronic references for general drug information (62% and 55%, respectively) and DDI information (51% and 79%, respectively). CONCLUSION: Respondents reported neutral to positive views regarding the effect of CPOE on their jobs. Their opinions suggest DDI alerts are useful but still require additional work to increase their clinical utility.

Attitude of Health Personnel↗
PubMed2006

A pragmatic approach to implementing best practices for clinical decision support systems in computerized provider order entry systems.

Incorporation of clinical decision support (CDS) capabilities is required to realize the greatest benefits from computerized provider order entry (CPOE) systems. Discussions at a conference on CDS in CPOE held in San Francisco, California, June 21-22, 2005 produced several papers in this issue of JAMIA. The first paper reviews CDS for electronic prescribing within CPOE systems; (1) the second describes current controversies regarding creation, maintenance, and uses of CPOE order sets for CDS; (2) and the third presents issues related to certification as a potential means of validating CPOE systems for widespread use. (3) This manuscript summarizes all of the discussions at the meeting and provides a pragmatically oriented view of how to implement CPOE with CDS.

Certification↗
PubMed2006

A socio-technical study of an ubiquitous CPOE-system in local use.

A socio-technical approach was used to study the qualitative effects of deploying a medication-CPOE (Computer-based Provider Order Entry System) at two internal medical wards on a hospital in Denmark. Our results show spatial and temporal transformations of core acts in medication work, transformation in competencies, and less time spent at the bedside for nurses and doctors, as a system--constructed for ubiquitous drug-order entries and handling--was implemented for local use. This study throws light on problems of patient continuity, patient-related and IT-system-related error-handling and time spend on core activities--when ubiquitous IT is used locally in a real physical setting with specific traditions of doing medication acts. The paper argues for the project organization to support the local renegotiation of time and place of programs of (work-)action and of collaboration with 'ubiquitous' CPOE-systems, as well as set up feed-back for maturation of software for future clinical use.

Denmark↗
PubMed2006

The significance of a usability evaluation of an emerging laboratory order entry system.

OBJECTIVES: To assess the usability of an emerging POE system, OM/Lab, for the computer-supported ordering of laboratory tests. We were more specifically interested in the relation of the usability problems detected in the user testing sessions with the order behaviour in terms of efficiency and errors in ordering. METHODS: A cognitive walkthrough of the OM/Lab system was conducted by two analysts using four real-life scenarios for ordering laboratory tests, which were reviewed for comprehensiveness by an expert clinician. Thereafter, the OM/Lab system was evaluated on its usability in testing sessions with seven potential end-users of the system performing these same four scenarios. The results of these end-user testing sessions were used to analyze the effect of usability flaws on the quality of ordering in terms of omissions, errors in orders and cancelled orders. RESULTS: The analyses revealed a total of 33 usability problems, of which 25 problems were revealed both by the cognitive walkthrough and in the end-user sessions. These 25 usability problems indeed led to inefficient order behaviour, omissions and errors in orders and even to cancelled orders. DISCUSSION: Our results revealed that the OM/Lab system suffered from a high number of usability flaws. The interface design flaws were, among other things, related to misallocation of buttons on the screen, incomprehensibility of button labels and feedback containing no relevant information to the user about the cause of errors made and consequences of a user's action. Additionally, our user test session results indicated that the OM/Lab system also suffered from user interaction problems of a more socio-technical nature. These sessions revealed, among other things, that the more specific action sequences to be executed within the ordering model of the OM/Lab system did not correspond to the daily working routines of end-users and that the grouping of laboratory tests within clusters did not match the paper-based order forms. The seemingly negative effects of these usability flaws on the quality of ordering and the inefficiency of work processes during the pilot implementation finally lead to withdrawal of the OM/Lab system from clinical practice. Though the system implementation failed, our usability study brought research on (re)designing and evaluating clinical computer applications at a higher status in our institution. It is now recognized that usability evaluation studies that will support good quality of clinical practice are highly important.

Clinical Laboratory Information Systems↗
PubMed2005

Determinants of physician use of an ambulatory prescription expert system.

PURPOSE: To determine whether physician experience with and attitude towards computers is associated with adoption of a voluntary ambulatory prescription writing expert system. METHODS: A prescription expert system was implemented in an academic internal medicine residency training clinic and physician utilization was tracked electronically. A physician attitude and behavior survey (response rate=89%) was conducted six months after implementation. RESULTS: There was wide variability in system adoption and degree of usage, though 72% of physicians reported predominant usage (> or =50% of prescriptions) of the expert system six months after implementation. Self-reported and measured technology usage were strongly correlated (r=0.70, p<0.0001). Variation in use was strongly associated with physician attitude toward issues of system efficiency and effect on quality, but not with prior computer experience, level of training, or satisfaction with their primary care practice. Non-adopters felt that electronic prescribing was more time consuming and also more likely to believe that their patients preferred hand-written prescriptions. CONCLUSION: A voluntary electronic prescription system was readily adopted by a majority of physicians who believed it would have a positive impact on the quality and efficiency of care. However, dissatisfaction with system capabilities among both adopters and non-adopters suggests the importance of user education and expectation management following system selection.

Ambulatory Care Information Systems↗
PubMed2005

Medication safety issue brief, Look-alike, sound-alike drugs.

Confusing drugs with similar names accounts for about 10 percent of all medication errors, according to the Food and Drug Administration. Last year, the American Pharmacists Association reported that there are more than 33,000 trademarked medication names in the United States and more than 9,000 generic names. The large number of medications--added to clinicians' heavy workloads, job stress, unfamiliarity with drug names and confusing, unclear orders, among other things--creates ample opportunity for confusion. A Joint Commission on Accreditation of Healthcare Organizations' National Patient Safety Goal requires that hospitals identify and annually review a list of look-alike and sound-alike drugs, at minimum, and take action to prevent errors involving the interchange of these drugs.

Clinical Pharmacy Information Systems↗
PubMed2003

Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review.

BACKGROUND: Iatrogenic injuries related to medications are common, costly, and clinically significant. Computerized physician order entry (CPOE) and clinical decision support systems (CDSSs) may reduce medication error rates. METHODS: We identified trials that evaluated the effects of CPOE and CDSSs on medication safety by electronically searching MEDLINE and the Cochrane Library and by manually searching the bibliographies of retrieved articles. Studies were included for systematic review if the design was a randomized controlled trial, a nonrandomized controlled trial, or an observational study with controls and if the measured outcomes were clinical (eg, adverse drug events) or surrogate (eg, medication errors) markers. Two reviewers extracted all the data. Discussion resolved any disagreements. RESULTS: Five trials assessing CPOE and 7 assessing isolated CDSSs met the criteria. Of the CPOE studies, 2 demonstrated a marked decrease in the serious medication error rate, 1 an improvement in corollary orders, 1 an improvement in 5 prescribing behaviors, and 1 an improvement in nephrotoxic drug dose and frequency. Of the 7 studies evaluating isolated CDSSs, 3 demonstrated statistically significant improvements in antibiotic-associated medication errors or adverse drug events and 1 an improvement in theophylline-associated medication errors. The remaining 3 studies had nonsignificant results. CONCLUSIONS: Use of CPOE and isolated CDSSs can substantially reduce medication error rates, but most studies have not been powered to detect differences in adverse drug events and have evaluated a small number of "homegrown" systems. Research is needed to evaluate commercial systems, to compare the various applications, to identify key components of applications, and to identify factors related to successful implementation of these systems.

Cost-Benefit Analysis↗
PubMed2005

Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system.

OBJECTIVE: In response to the landmark 1999 report by the Institute of Medicine and safety initiatives promoted by the Leapfrog Group, our institution implemented a commercially sold computerized physician order entry (CPOE) system in an effort to reduce medical errors and mortality. We sought to test the hypothesis that CPOE implementation results in reduced mortality among children who are transported for specialized care. METHODS: Demographic, clinical, and mortality data were collected of all children who were admitted via interfacility transport to our regional, academic, tertiary-care level children's hospital during an 18-month period. A commercially sold CPOE program that operated within the framework of a general, medical-surgical clinical application platform was rapidly implemented hospital-wide over 6 days during this period. Retrospective analyses of pre-CPOE and post-CPOE implementation time periods (13 months before and 5 months after CPOE implementation) were subsequently performed. RESULTS: Among 1942 children who were referred and admitted for specialized care during the study period, 75 died, accounting for an overall mortality rate of 3.86%. Univariate analysis revealed that mortality rate significantly increased from 2.80% (39 of 1394) before CPOE implementation to 6.57% (36 of 548) after CPOE implementation. Multivariate analysis revealed that CPOE remained independently associated with increased odds of mortality (odds ratio: 3.28; 95% confidence interval: 1.94-5.55) after adjustment for other mortality covariables. CONCLUSIONS: We have observed an unexpected increase in mortality coincident with CPOE implementation. Although CPOE technology holds great promise as a tool to reduce human error during health care delivery, our unanticipated finding suggests that when implementing CPOE systems, institutions should continue to evaluate mortality effects, in addition to medication error rates, for children who are dependent on time-sensitive therapies.

Child Mortality↗
PubMedDate not supplied

A critical change in a day in the life of intensive care nurses: rising to the e-challenge of an integrated clinical information system.

Critical care nurses in a large academic, tertiary care trauma center have adapted to a major system change since the implementation of a fully integrated Computerized Provider Order Entry (CPOE) system, an automated process of order entry. Working in a rapidly changing environment, clinicians are accustomed to viewing real-time discrete data and then using that data to provide safe, effective, and efficient intensive care to critically ill patients. This article describes how the implementation of the CPOE system from a major healthcare software vendor has changed the life of critical care nurses and the perceptions of the experience 1 year after the new technology was initiated. Through experience sharing, perhaps others may gain knowledge to ease their transition to CPOE.

Adult↗
PubMed1984

The pharmacy computer system at the New England Medical Center.

The pharmacy computer system developed and implemented at the New England Medical Center (NEMC) is described. The system was developed to improve the department's fiscal performance and operations. It operates on NEMC's large mainframe system and has the following components-order entry, unit dose/patient profile, i.v. admixture, and financial/management. The system was designed to interface with the admissions and census system and use the pharmacy department's drug data file. It accepts medication orders from pharmacy satellites and then processes the orders according to the requirements for the i.v. admixture or unit dose procedures. Financial data are collected as a routine part of all medication order processing. The system allows for the entry of multiple medication orders on one cathode ray tube (CRT) screen, thus facilitating order entry. The use of programmed system defaults is described. Order entry, dose selection, and patient profiles are displayed on a CRT. An active order list is printed once daily at midnight to serve as a back-up for the system. The computer system has had a positive impact on the department's operational, clinical, and management functions. Future enhancements of the NEMC system are discussed.

Allied Health Personnel↗
PubMedDate not supplied

Nurse's role in tracking adverse drug events: the impact of provider order entry.

Adverse drug events (ADE), or injuries caused by drug therapy, are a frequent and serious problem in hospitalized patients. Monitoring, preventing, and treating ADEs is an important patient safety function. Nurses play a significant role in this function, because their data is a unique and important indicator of ADEs and because they are the final point of medication administration. New provider order entry systems with electronic medical records have been viewed as an effective innovation and solution to high rates of ADEs. These systems increase legibility of drug orders, provide decision support, and increase access to the medical record. However, they may not interface with nursing processes effectively. This study reports the experience of a team conducting an ADE surveillance study in a Veterans Health Administration setting where extensive computerized innovations are in place. Lessons learned regarding the integration of nursing work processes with the computerized setting are described. Three areas of concern are highlighted: decreased access to nursing narratives, lack of decision support for medication administration, and failure to code nursing data. Each of these is discussed in terms of relevance to patient safety and the design of information systems.

Female↗