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Antiretroviral medication errors among hospitalized patients with HIV infection.

BACKGROUND: Highly active antiretroviral therapy (HAART) has improved survival for persons living with human immunodeficiency virus (HIV) infection. However, effective therapy requires high levels of adherence over extended periods of time. Previous studies suggest that patients receiving long-term medication are at risk for unintended medication discrepancies at the time of hospital admission. METHODS: We retrospectively identified every HIV-infected patient admitted to our hospital over a 1-year period who received an antiretroviral agent. We collected information on medications and renal function from the hospital computerized provider order entry system. We reviewed the medical records for those admissions for which a potential error was identified. We defined errors using Department of Health and Human Services guidelines and included only those errors that were not corrected within 24 h after initial entry. RESULTS: There were a total of 209 admissions during a 1-year period in which an HIV-infected patient received antiretroviral therapy. After review of the medical records for 77 admissions with a potential error, 61 uncorrected errors from 54 admissions were identified (percentage of total admissions, 25.8%; 95% confidence interval, 20.1%-32.3%). The most common type of error was an error with respect to the amount or frequency of dosage, which occurred in 34 (16.3%) of the admissions; 18 of these errors were attributable to failure to appropriately adjust dosage for renal insufficiency. The next most common error was combining antiretroviral drugs with a contraindicated medication; this occurred in 12 (5.2%) of the admissions. Patients erroneously received <or=2 antiretroviral agents in 8 (3.8%) of the admissions and had an unexplained delay in continuing HAART in 7 (3.3%). CONCLUSIONS: HIV-infected patients receiving HAART are at substantial risk for antiretroviral medication errors at the time of hospitalization. More needs to be done to ensure that these patients receive appropriate therapy during their inpatient stay.

Anti-Retroviral Agents↗

Clinical application of the UMLS in a computerized order entry and decision-support system.

Vanderbilt University Medical Center uses the UMLS as a dictionary, an interlingua, and a knowledge source within the WizOrder system. WizOrder provides direct care-provider order entry and integrated clinical decision-support capabilities. Linking the two functions enables efficient decision-support during the "normal" workflow of care providers, at the point where decisions are made. WizOrder uses the UMLS as a dictionary to encode free-text entries into controlled vocabularies such as ICD9. As an interlingua, the UMLS provides mapping between vocabularies, allowing to translate patient-specific information to MeSH terms and perform automated literature retrieval. WizOrder uses the tables of co-occurring concepts and the Semantic Network to provide sensible lists of potential drug interactions and adverse drug reactions, and generate fully-formed MEDLINE queries for PubMed.

Decision Support Systems, Clinical↗

Implementing outpatient order entry to support medical necessity using the patient's electronic past medical history.

Physician order entry is difficult to implement, both in inpatient and outpatient settings. Such systems must integrate conveniently into clinical workflows, and provide sufficient benefit to offset the burden of system use. For outpatient order entry, significant advantages can accrue when systems incorporate medical necessity guidelines - improved billing and adherence to governmental policies. The authors developed and implemented an outpatient order entry system that utilizes an electronically accessible history of patient, provider, and clinic-related diagnoses in assisting providers (when possible and appropriate) to select compliant justifications for tests and procedures. The pilot implementation site, active for more than six months, has been the Vanderbilt University Page Campbell Cardiology Clinic, with 34 providers.

Ambulatory Care↗

Analysis of the online order entry process in an integrated hospital information system.

In Kochi Medical School Hospital, many online order systems have been developed as a part of the integrated hospital information system named IMIS KOCHI. The prescription, laboratory and radiology orders are used frequently and entered into the system by physicians. The distribution of entry duration of these orders by physicians was analyzed and it was found that the order entry is a completely random event and the entry process consists of the two Poisson processes; the quick process and the slow process. The two Poisson processes were observed even in the do-prescription order without correction by trained physicians. It is speculated that the quick process depends on availability in the order entry system and the slow process depends on peculiarities in clinics, and the mental condition of physicians.

Drug Prescriptions↗

Clinicians' perceptions of clinical decision support integrated into computerized provider order entry.

Computerized provider order entry systems can improve patient care by integrating clinical decision support. Decision support is most effective when its content and delivery are acceptable. The authors report the results of a multifaceted survey of the attitudes of housestaff and medical student users of a provider order entry system with integrated decision support at an academic medical center. The survey contained 16 items covering four themes: efficiency, quality of care, results reporting and embedded guidelines. Responses were captured using a five point Likert scale, and were compared using ANOVA and Bartlett's testing. Out of 491 housestaff and 128 medical students, response rates were 47 and 29%, respectively. Among respondents, 72% agreed or strongly agreed that the provider order entry system improves the quality of care that they provide, 54% that the decision support usually help them to provide quality patient care, and 62% that it improves the efficiency of order entry. Respondents were least likely to agree that the display of prior laboratory results influenced their decision to order a subsequent test. There were no significant differences between subspecialties and by advancing years of training among housestaff. Respondents agreed that the integrated clinical decision support enhanced their medical training.

Attitude of Health Personnel↗

Effect of decentralized computer order entry on medication turnaround time.

The medication order turnaround times of two drug-distribution systems in the same hospital using either centralized or decentralized computer order entry were compared. A decentralized medication order entry satellite pharmacy equipped with a pharmacy computer terminal and a small supply of medications typically requested to be administered without delay was implemented on one floor of a 518-bed hospital. Pharmacist-verified medication orders for five of the hospital's 22 nursing units were entered into the satellite computer terminal and transmitted to the central pharmacy for processing. Initial doses of medication dispensed from the satellite's drug supply were noted in the central pharmacy. Pharmacy personnel recorded time they spent in various steps of the medication delivery cycle for routine medication orders handled by the decentralized pharmacy. The same measurements were made for the centralized pharmacy system before implementation of the pharmacy satellite. The mean turnaround time for routine medication orders in the decentralized system was 79.5 minutes, which was 52% less than that of the centralized system (167.3 minutes). Decentralized computer order entry appears to be an effective way of decreasing turnaround time for routine medication orders.

Computers↗

The future is now: implementation of a tele-intensivist program.

Based on overwhelming scientific evidence, The Leapfrog Group focused on 3 practices that have tremendous potential to save lives by reducing preventable mistakes in hospitals. The authors describe these practices and how they served as a driving force to create a "virtual ICU" within a Magnet hospital network. The effort combined services of a board-certified intensivist and technological advancements in telemedicine to ensure the delivery of high-quality care to all critically ill patients throughout the network. A computerized physician-order entry system, an electronic medication administration record, an electronic documentation system, and a remote ICU were the 4 programmatic phases necessary to realize the concept. The purpose of this article is to describe the process of planning and implementing the tele-intensivist program.

Critical Care↗

Nurses--yes, nurses--improve physician order entry.

Automated physician order entry systems can reduce medication errors and improve patient outcomes. But there are a variety of barriers--psychological, behavioral and technological--to physician adoption. Nursing not only has a stake in this issue, but plays a valuable role in resolving it.

Forms and Records Control↗

Use of computerized clinical support systems in medical settings: United States, 2001-03.

OBJECTIVES: This report presents information on the use of electronic clinical systems to support patient care in physician offices and hospital emergency and outpatient settings. Percentages of hospital emergency and outpatient departments with electronic patient medical records and automated drug dispensing systems are presented by selected hospital characteristics for 2001-02. Percentages of physicians using electronic patient billing records, electronic patient medical records, and computerized prescription order entry systems are presented by selected physician characteristics for 2003. METHODS: Data are from provider induction interviews from the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS), the ambulatory care component of the National Health Care Survey (NHCS). The NHCS is a family of provider-based surveys that collect information on the care provided in various medical care settings. RESULTS: During 2001-03, electronic medical records were used less often in physician offices (17 percent) than in hospital emergency (31 percent) and outpatient departments (29 percent). In physician offices, information technology was more frequently used for billing patients (73 percent) than for maintaining medical records electronically (17 percent) or ordering prescriptions electronically (8 percent). Automated drug dispensing systems were available in hospital emergency departments (40 percent) more frequently than in outpatient departments (18 percent).

Ambulatory Care↗

Sharable representation of clinical guidelines in GLIF: relationship to the Arden Syntax.

Clinical guidelines are intended to improve the quality and cost effectiveness of patient care. Integration of guidelines into electronic medical records and order-entry systems, in a way that enables delivery of patient-specific advice at the point of care, is likely to encourage guidelines acceptance and effectiveness. Among the methodologies for modeling guidelines and medical decision rules, the Arden Syntax for Medical Logic Modules and the GuideLine Interchange Format version 3 (GLIF3) emphasize the importance of sharing encoded logic across different medical institutions and implementation platforms. These two methodologies have similarities and differences; in this paper we clarify their roles. Both methods can be used to support sharing of medical knowledge, but they do so in complementary situations. The Arden Syntax is suitable for representing individual decision rules in self-contained units called Medical Logic Modules (MLMs), which are usually implemented as event-driven alerts or reminders. In contrast, GLIF3 is designed for encoding complex multistep guidelines that unfold over time. As a consequence, GLIF3 has several mechanisms for complexity management and additional constructs that may require overhead unnecessary for expressing simple alerts and reminders. Unlike the Arden Syntax, GLIF3 encourages a top-down process of guideline modeling consisting of three levels that are created in order: Level 1 comprises a human-readable flowchart of clinical decisions and actions. Level 2 comprises a computable specification that can be verified for logical consistency and completeness; and Level 3 comprises an implementable specification that includes information required for local adaptation of guideline logic as well as for mapping guideline variables onto institutional medical records. A major emphasis of the current GLIF3 development process has been to create the computable specification that formally represents medical decision and eligibility criteria. We based GLIF3's formal expression language on the Arden Syntax's logic grammar, making the necessary extensions to the Arden Syntax's data structures and operators to support GLIF3's object-oriented data model. We discuss why the process of generating a set of MLMs from a GLIF-encoded guideline cannot be automated, why it can result in information loss, and why simple medical rules are best represented as individual MLMs. We thus show that the Arden Syntax and GLIF3 play complementary roles in representing medical knowledge for clinical decision support.

Computer Simulation↗

[Decision support of clinical laboratory test by object-oriented data base].

We have constructed an object-oriented database system, using prescription, lab test result, and disease registry data, transmitted from the order entry system of Hamamatsu University Medical School Hospital. It serves not only numeric data but also semantics of laboratory results. The database system has a feature to categorize each data into structured hierarchies of attributes. By this, the user can retrieve abstract level descriptions such as "prescriptions of anti-inflammation medicines, suppository only", "any kind of gastric ulcer", etc., which is expected to be useful for researchers and students. In transferring order entry data from HIS, HL7-ASTM E1238 standard data formats using the Japan Association of Clinical Pathology lab test item code are utilized, proving this system's transferability to other hospitals. This is the first real use implementation of an object-oriented data base in a clinical setting, and results are promising in terms of providing an intelligent clinical database. Also discussed are future trends of clinical master files, hospital administrative tools, and multi vendor configurations of HIS.

Clinical Laboratory Techniques↗

Introducing physician order entry at a major academic medical center: I. Impact on organizational culture and behavior.

In 1988 the University of Virginia Medical Center began implementation of a medical information system based on mandatory physician order entry. The implementation process was much more difficult than expected. The program experienced considerable delays, and cost much more than was originally estimated. Although there were some legitimate questions concerning the user-friendliness of the new technology, these were less significant than the cultural and behavioral problems encountered. The new system challenged basic institutional assumptions; it disturbed traditional patterns of conduct and forced people to modify established practice routines. Real progress toward the integration of the system into the center's operational culture occurred only after a senior management team representing important sectors of the hospital staff and administration began meeting regularly to address the institution-wide issues that had been raised. The author describes the problems that occurred and the organizational behaviors on which they were based, analyzes the lessons learned, documents the progress that has been achieved, and outlines the challenges that remain. The center's experience provides insight into the issue of technology-driven organizational transformation in academic medical centers. Recommendations for successful introduction of similar agents of institutional change are presented.

Academic Medical Centers↗

Computerized physician order entry systems in hospitals: mandates and incentives.

Concerns with health care quality and medical errors are evident in media reports and research studies. A number of studies have demonstrated that computerized physician order entry (CPOE) can reduce medication error rates. In response, the California government and the Leapfrog Group have called for hospitals to implement CPOE for medications. However, few hospitals now use CPOE. Barriers include the large investment needed and the state of commercial CPOE systems. We argue that government, employers, and insurers should share the costs of CPOE and should fund further research into its benefits and means of implementation.

Attitude to Computers↗

Promoting patient safety: is technology the solution?

BACKGROUND: On April 30, 2001, the Cleveland Clinic Foundation and Cleveland Clinic Health System Quality Institute sponsored a 1-day conference focused on technology in patient safety. PATIENT SAFETY-A CALL TO ACTION: Kenneth W. Kizer focused on ten high-priority patient safety strategies identified by the National Quality Forum-including implementing recognized "safe practices", recognizing and dealing with professional misconduct, and supporting efforts to create a nonpunitive environment for health care error reporting. CULTURAL IMPLICATIONS OF INTRODUCING NEW TECHNOLOGY: Randolph A. Miller described a computerized clinician order-entry system used to provide decision support, reduce excess test ordering, introduce cost savings, and meet regulations for inpatient radiology and cardiology tests. USING BAR CODES TO ELIMINATE MEDICATION ERRORS: Jeff Ramirez reported on the Veterans Health Administration's use of bar coding technology for point-of-care validation of medication administration, which has resulted in improvements in response time; the efficiency of the dispensing, delivery, and administration process; and patient care. HOW TO MAKE COMPUTERS TEAM PLAYERS: The knowledge base exists to design computers as team players that expand human expertise and help health care practitioners better create safety. Yet David D. Woods challenged the audience to anticipate the changing shape of iatrogenic risk as a result of increasing dependence on automation in health care. TECHNOLOGY AND MEDICATION SYSTEMS: Mark Neuenschwander spoke about automating various steps within the medication use system, through computerized prescriber order entry and bedside scanning. FUTURE TECHNOLOGICAL POSSIBILITIES: Charles Denham suggested how technology may aid health care professionals in their care of patients, such as in using predictive modeling to identify the risks of therapeutic intervention.

Equipment Safety↗

Influence of computerised medication charts on medication errors in a hospital.

INTRODUCTION: In hospitals where computerised physician order entry systems will not be available in the near future, there is a need to explore other ways of reducing medication errors that occur in the drug ordering and delivery system. One of these ways is the use of a computerised medication chart that is updated daily. The aim of this study was to evaluate the frequency, types and potential clinical significance of drug prescription and administration errors by comparing a traditional medication distribution system (where the transcription of handwritten into printed medication orders takes 3-5 days and the transfer of medication orders was not complete) with the use of a computerised medication chart (which was updated daily by pharmacy assistants on the ward). METHODS: Data were collected during two 3-week periods, from a 32-bed internal medicine unit, before and after the introduction of the computerised medication charts. Prescribing errors were observed by evaluation of all new and changed medication orders and administration errors were detected by using the disguised-observation technique. RESULTS: For prescribing errors, a total of 611 prescriptions before and 598 prescriptions after the intervention were evaluated. The total prescription error rate (of medication orders with >or=1 error) was found to be significantly higher with the computerised charts when compared with the old system (50.0% [299 of 598] vs 20.3% [124 of 611], odds ratio [OR] 3.80 [95% CI 2.94, 4.90]). This increase was caused by an increase in administrative prescription errors with a low potential clinical significance (mainly omission of the prescriber's name and the prescription date). The error rate for errors with a potential clinical significance was found to be significantly lower because the prescription error 'duplicate therapy' was eliminated (3.4% with the traditional medication chart vs 0% with the computerised chart). For administration errors, a total of 1122 drugs before the intervention and 1175 drugs after the intervention was observed to be administered. The total administration error rate was found to be significantly lower after the intervention (6.1% [72 of 1175] vs 10.5% [118 of 1122], OR 0.61 [95% CI 0.45, 0.84]), as was the error rate with a potential clinical significance. The contribution of handwritten medication orders to the total amount of medication orders was significantly decreased after the intervention (12.8% vs 20.6% [95% CI 4.6, 11.0]) and the administration of a drug ordered by a handwritten medication order resulted in a significantly higher administration rate than with administration of a drug ordered by a printed medication order (before the intervention 20.7% vs 8.0%, OR 2.99 [95% CI 1.96, 4.56], after the intervention 11.4% vs 5.6%, OR 2.18 [95% CI 1.16, 4.11]). CONCLUSION: This observational study shows a significant reduction in clinically relevant, administration and (therapeutic) prescription error rates when applying a system using computerised and daily updated medication charts compared with a system using traditional medication charts. Therefore, the use of computerised and daily updated medication charts has the potential to improve the quality of the medication distribution process in hospitals waiting for the implementation of a computerised physician order entry system.

Aged↗

Educational instruction on a hospital information system for medical students during their surgical rotations.

OBJECTIVE: To evaluate the benefit, for medical students on their surgical rotations, of real-time educational instruction during order entry on a hospital information system. DESIGN: Prospective controlled trial. INTERVENTION: Access to educational information during computerized order entry. SUBJECTS: Medical students in their final year at the University of Calgary. MAIN OUTCOMES: Attainment of the surgery rotation educational objectives, as measured by performance on a multiple-choice examination. METHODS: Before they began their surgical rotations, students at two hospitals took a multiple-choice examination to measure their knowledge of surgery. One hospital had an information system with computerized order entry; students at this hospital had access, while composing orders, to educational material on the system. The other hospital did not have an information system; students there wrote orders on a paper chart. At the end of the rotation, all students took another multiple-choice examination. RESULTS: Of 50 eligible students, 45 agreed to participate in the project, 21 in the treatment group and 24 in the control group. Pre-rotation scores were similar for the two groups (43 percent in the treatment group and 40 percent in the control group; SD, 10 percent). Post-rotation scores were identical for the two groups (65 percent in the treatment group and 65 percent in the control group; SD, 12 percent). A t-test analysis revealed no significant difference in performance on the examinations between the two groups. CONCLUSION: This study did not demonstrate a learning advantage for medical students who have access to educational material on a hospital information system.

Alberta↗