Clinical decision support for atypical orders: detection and warning of atypical medication orders submitted to a computerized provider order entry system.
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ABSTRACT:
SUBMITTER: Woods AD
PROVIDER: S-EPMC3994864 | biostudies-literature | 2014 May-Jun
REPOSITORIES: biostudies-literature
Publications
Clinical decision support for atypical orders: detection and warning of atypical medication orders submitted to a computerized provider order entry system.
Woods Allie D AD Mulherin David P DP Flynn Allen J AJ Stevenson James G JG Zimmerman Christopher R CR Chaffee Bruce W BW
Journal of the American Medical Informatics Association : JAMIA 20131119 3
The specificity of medication-related alerts must be improved to overcome the pernicious effects of alert fatigue. A systematic comparison of new drug orders to historical orders could improve alert specificity and relevance. Using historical order data from a computerized provider order entry system, we alerted physicians to atypical orders during the prescribing of five medications: calcium, clopidogrel, heparin, magnesium, and potassium. The percentage of atypical orders placed for these five ...[more]
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Project description:Study objectiveWe evaluate the short- and long-term effect of a computerized provider order entry-based patient verification intervention to reduce wrong-patient orders in 5 emergency departments.MethodsA patient verification dialog appeared at the beginning of each ordering session, requiring providers to confirm the patient's identity after a mandatory 2.5-second delay. Using the retract-and-reorder technique, we estimated the rate of wrong-patient orders before and after the implementation of the intervention to intercept these errors. We conducted a short- and long-term quasi-experimental study with both historical and parallel controls. We also measured the amount of time providers spent addressing the verification system, and reasons for discontinuing ordering sessions as a result of the intervention.ResultsWrong-patient orders were reduced by 30% immediately after implementation of the intervention. This reduction persisted when inpatients were used as a parallel control. After 2 years, the rate of wrong-patient orders remained 24.8% less than before intervention. The mean viewing time of the patient verification dialog was 4.2 seconds (SD=4.0 seconds) and was longer when providers indicated they placed the order for the wrong patient (4.9 versus 4.1 seconds). Although the display of each dialog took only seconds, the large number of display episodes triggered meant that the physician time to prevent each retract-and-reorder event was 1.5 hours.ConclusionA computerized provider order entry-based patient verification system led to a moderate reduction in wrong-patient orders that was sustained over time. Interception of wrong-patient orders at data entry is an important step in reducing these errors.
| S-EPMC4447590 | biostudies-literature
Project description:BackgroundPrescribing is a high-risk task within the pediatric medication-use process and requires defenses to prevent errors. Such system-centric defenses include electronic health record systems with computerized physician order entry (CPOE) and clinical decision support (CDS) tools that assist safe prescribing. The objective of this study was to examine the effects of CPOE systems with CDS functions in preventing dose errors in pediatric medication orders.Material and methodsThis study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 criteria and Synthesis Without Meta-Analysis (SWiM) items. The study protocol was registered in PROSPERO (CRD42021277413). The final literature search on MEDLINE (Ovid), Scopus, Web of Science, and EMB Reviews was conducted on 10 September 2023. Only peer-reviewed studies considering both CPOE and CDS systems in pediatric inpatient or outpatient settings were included. Study selection, data extraction, and evidence quality assessment (JBI critical appraisal tool assessment and GRADE approach) were carried out by two individual reviewers. Vote counting method was used to evaluate the effects of CPOE-CDS systems on dose errors rates.ResultsA total of 17 studies published in 2007-2021 met the inclusion criteria. The most used CDS tools were dose range check (n = 14), dose calculator (n = 8), and dosing frequency check (n = 8). Alerts were recorded in 15 studies. A statistically significant reduction in dose errors was found in eight studies, whereas an increase of dose errors was not reported.ConclusionsThe CPOE-CDS systems have the potential to reduce pediatric dose errors. Most beneficial interventions seem to be system customization, implementing CDS alerts, and the use of dose range check. While human factors are still present within the medication use process, further studies and development activities are needed to optimize the usability of CPOE-CDS systems.
| S-EPMC10891203 | biostudies-literature
Project description:ObjectiveComputerized provider order entry (CPOE) has been shown to improve patient safety by reducing medication errors and subsequent adverse drug events (ADEs). Studies demonstrating these benefits have been conducted primarily in the inpatient setting, with fewer in the ambulatory setting. The objective was to evaluate the effect of a basic, ambulatory CPOE system on medication errors and associated ADEs.DesignThis quasiexperimental, pretest-post-test study was conducted in a community-based, multispecialty health system not affiliated with an academic medical center. The intervention was a basic CPOE system with limited clinical decision support capabilities.MeasurementComparison of prescriptions written before (n=5016 handwritten) to after (n=5153 electronically prescribed) implementation of the CPOE system. The primary outcome was the occurrence of error(s); secondary outcomes were types and severity of errors.ResultsFrequency of errors declined from 18.2% to 8.2%-a reduction in adjusted odds of 70% (OR: 0.30; 95% CI 0.23 to 0.40). The largest reductions were seen in adjusted odds of errors of illegibility (97%), use of inappropriate abbreviations (94%) and missing information (85%). There was a 57% reduction in adjusted odds of errors that did not cause harm (potential ADEs) (OR 0.43; 95% CI 0.38 to 0.49). The reduction in the number of errors that caused harm (preventable ADEs) was not statistically significant, perhaps due to few errors in this category.ConclusionsA basic CPOE system in a community setting was associated with a significant reduction in medication errors of most types and severity levels.
| S-EPMC2995630 | biostudies-literature
Project description:BackgroundComputerized provider order entry (CPOE) is the process of entering physician orders directly into an electronic health record. Although CPOE has been shown to improve medication safety and reduce health care costs, these improvements have been demonstrated largely in the inpatient setting; the cost-effectiveness in the ambulatory setting remains uncertain.ObjectiveThe objective was to estimate the cost-effectiveness of CPOE in reducing medication errors and adverse drug events (ADEs) in the ambulatory setting.MethodsWe created a decision-analytic model to estimate the cost-effectiveness of CPOE in a midsized (400 providers) multidisciplinary medical group over a 5-year time horizon- 2010 to 2014-the time frame during which health systems are implementing CPOE to meet Meaningful Use criteria. We adopted the medical group's perspective and utilized their costs, changes in efficiency, and actual number of medication errors and ADEs. One-way and probabilistic sensitivity analyses were conducted. Scenario analyses were explored.ResultsIn the base case, CPOE dominated paper prescribing, that is, CPOE cost $18 million less than paper prescribing, and was associated with 1.5 million and 14,500 fewer medication errors and ADEs, respectively, over 5 years. In the scenario that reflected a practice group of five providers, CPOE cost $265,000 less than paper prescribing, was associated with 3875 and 39 fewer medication errors and ADEs, respectively, over 5 years, and was dominant in 80% of the simulations.ConclusionsOur model suggests that the adoption of CPOE in the ambulatory setting provides excellent value for the investment, and is a cost-effective strategy to improve medication safety over a wide range of practice sizes.
| S-EPMC4079669 | biostudies-literature
Project description:ImportanceConventional approaches for tracking postoperative adverse events requires manual medical record review, thus limiting the scalability of such efforts.ObjectiveTo determine if a surveillance system using computerized provider order entry (CPOE) events for selected medications as well as laboratory, microbiologic, and radiologic orders can decrease the manual medical record review burden for surveillance of postoperative complications.Design, setting, and participantsThis cohort study reviewed the medical records of 21 775 patients who underwent surgical procedures at a university-based tertiary referral center (University of Utah, Salt Lake City) from July 1, 2007, to August 31, 2017. Patients were included if their case was selected for review by a surgical clinical reviewer as part of the National Surgical Quality Improvement Program. Patients were excluded if they had incomplete follow-up data.Main outcomes and measuresThirty-day postoperative occurrences of superficial surgical site infection, deep surgical site infection, organ space surgical site infection, urinary tract infection, pneumonia, sepsis, septic shock, deep vein thrombosis requiring therapy, and pulmonary embolism, as defined by the National Surgical Quality Improvement Program. A logistic regression model was developed for each postoperative complication using CPOE features as predictors on a development set, and performance was measured on a holdout internal validation set. The models were internally validated using bootstrapping with 10 000 replications to determine the sensitivity, specificity, positive predictive value, and negative predictive value of CPOE-based surveillance system.ResultsThe study included 21 775 patients who underwent surgical procedures. Among these patients, 11 855 (54.4%) were women and 9920 (45.6%) were men, with a mean (SD) age of 51.7 (16.8) years. Overall, the prevalence of postoperative complications was low, ranging from 0.2% (pulmonary embolism) to 2.6% (superficial surgical site infection). Use of CPOE events to detect patients who experienced at least 1 complication had a sensitivity of 74.8% (95% CI, 71.1%-78.4%), specificity of 86.8% (95% CI, 85.5%-88.3%), positive predictive value of 33.8% (95% CI, 31.2%-36.4%), negative predictive value of 97.5% (95% CI, 97.1%-97.8%), and area under the curve of 0.808 (95% CI, 0.791-0.824). The negative predictive value for individual complications ranged from 98.7% to 100%. Use of CPOE events to screen for adverse events was estimated to diminish the burden of manual medical record review by 55.4% to 90.3%. A CPOE-based surveillance system performed well for both inpatient and outpatient procedures.Conclusions and relevanceA CPOE-based surveillance of postoperative complications has high negative predictive value, which demonstrates that this approach can augment the currently used, resource-intensive manual medical record review process.
| S-EPMC6484794 | biostudies-literature
Project description:ObjectiveTo examine medication errors potentially related to computerized prescriber order entry (CPOE) and refine a previously published taxonomy to classify them.Materials and methodsWe reviewed all patient safety medication reports that occurred in the medication ordering phase from 6 sites participating in a United States Food and Drug Administration-sponsored project examining CPOE safety. Two pharmacists independently reviewed each report to confirm whether the error occurred in the ordering/prescribing phase and was related to CPOE. For those related to CPOE, we assessed whether CPOE facilitated (actively contributed to) the error or failed to prevent the error (did not directly cause it, but optimal systems could have potentially prevented it). A previously developed taxonomy was iteratively refined to classify the reports.ResultsOf 2522 medication error reports, 1308 (51.9%) were related to CPOE. Of these, CPOE facilitated the error in 171 (13.1%) and potentially could have prevented the error in 1137 (86.9%). The most frequent categories of "what happened to the patient" were delays in medication reaching the patient, potentially receiving duplicate drugs, or receiving a higher dose than indicated. The most frequent categories for "what happened in CPOE" included orders not routed to or received at the intended location, wrong dose ordered, and duplicate orders. Variations were seen in the format, categorization, and quality of reports, resulting in error causation being assignable in only 403 instances (31%).Discussion and conclusionErrors related to CPOE commonly involved transmission errors, erroneous dosing, and duplicate orders. More standardized safety reporting using a common taxonomy could help health care systems and vendors learn and implement prevention strategies.
| S-EPMC7651942 | biostudies-literature
Project description:BackgroundPharmacogenomics (PGx) is positioned to have a widespread impact on the practice of medicine, yet physician acceptance is low. The presentation of context-specific PGx information, in the form of clinical decision support (CDS) alerts embedded in a computerized provider order entry (CPOE) system, can aid uptake. Usability evaluations can inform optimal design, which, in turn, can spur adoption.ObjectivesThe study objectives were to: (1) evaluate an early prototype, commercial CPOE system with PGx-CDS alerts in a simulated environment, (2) identify potential improvements to the system user interface, and (3) understand the contexts under which PGx knowledge embedded in an electronic health record is useful to prescribers.MethodsUsing a mixed methods approach, we presented seven cardiologists and three oncologists with five hypothetical clinical case scenarios. Each scenario featured a drug for which a gene encoding drug metabolizing enzyme required consideration of dosage adjustment. We used Morae(®) to capture comments and on-screen movements as participants prescribed each drug. In addition to PGx-CDS alerts, 'Infobutton(®)' and 'Evidence' icons provided participants with clinical knowledge resources to aid decision-making.ResultsNine themes emerged. Five suggested minor improvements to the CPOE user interface; two suggested presenting PGx information through PGx-CDS alerts using an 'Infobutton' or 'Evidence' icon. The remaining themes were strong recommendations to provide succinct, relevant guidelines and dosing recommendations of phenotypic information from credible and trustworthy sources; any more information was overwhelming. Participants' median rating of PGx-CDS system usability was 2 on a Likert scale ranging from 1 (strongly agree) to 7 (strongly disagree).ConclusionsUsability evaluation results suggest that participants considered PGx information important for improving prescribing decisions; and that they would incorporate PGx-CDS when information is presented in relevant and useful ways.
| S-EPMC4095746 | biostudies-literature
Project description:ObjectiveTo conduct a systematic review and meta-analysis of the impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay (LOS), and mortality in intensive care units (ICUs).MethodsWe searched for English-language literature published between January 2000 and January 2016 using Medline, Embase, and CINAHL. Titles and abstracts of 586 unique citations were screened. Studies were included if they: (1) reported results for an ICU population; (2) evaluated the impact of CPOE or the addition of CDSSs to an existing CPOE system; (3) reported quantitative data on medication errors, ICU LOS, hospital LOS, ICU mortality, and/or hospital mortality; and (4) used a randomized controlled trial or quasi-experimental study design.ResultsTwenty studies met our inclusion criteria. The transition from paper-based ordering to commercial CPOE systems in ICUs was associated with an 85% reduction in medication prescribing error rates and a 12% reduction in ICU mortality rates. Overall meta-analyses of LOS and hospital mortality did not demonstrate a significant change.Discussion and conclusionCritical care settings, both adult and pediatric, involve unique complexities, making them vulnerable to medication errors and adverse patient outcomes. The currently limited evidence base requires research that has sufficient statistical power to identify the true effect of CPOE implementation. There is also a critical need to understand the nature of errors arising post-CPOE and how the addition of CDSSs can be used to provide greater benefit to delivering safe and effective patient care.
| S-EPMC7651905 | biostudies-literature
Project description:BackgroundComputerized provider order entry (CPOE) systems have been introduced to reduce medication errors, increase safety, improve work-flow efficiency, and increase medical service quality at the moment of prescription. Making the impact of CPOE systems more observable may facilitate their adoption by users. We set out to examine factors associated with the adoption of a CPOE system for inter-organizational and intra-organizational care.MethodsThe diffusion of innovation theory was used to understand physicians' and nurses' attitudes and thoughts about implementation and use of the CPOE system. Two online survey questionnaires were distributed to all physicians and nurses using a CPOE system in county-wide healthcare organizations. The number of complete questionnaires analyzed was 134 from 200 nurses (67.0%) and 176 from 741 physicians (23.8%). Data were analyzed using descriptive-analytical statistical methods.ResultsMore nurses (56.7%) than physicians (31.3%) stated that the CPOE system introduction had worked well in their clinical setting (P < 0.001). Similarly, more physicians (73.9%) than nurses (50.7%) reported that they found the system not adapted to their specific professional practice (P = < 0.001). Also more physicians (25.0%) than nurses (13.4%) stated that they did want to return to the previous system (P = 0.041). We found that in particular the received relative advantages of the CPOE system were estimated to be significantly (P < 0.001) higher among nurses (39.6%) than physicians (16.5%). However, physicians' agreements with the compatibility of the CPOE and with its complexity were significantly higher than the nurses (P < 0.001).ConclusionsQualifications for CPOE adoption as defined by three attributes of diffusion of innovation theory were not satisfied in the study setting. CPOE systems are introduced as a response to the present limitations in paper-based systems. In consequence, user expectations are often high on their relative advantages as well as on a low level of complexity. Building CPOE systems therefore requires designs that can provide rather important additional advantages, e.g. by preventing prescription errors and ultimately improving patient safety and safety of clinical work. The decision-making process leading to the implementation and use of CPOE systems in healthcare therefore has to be improved. As any change in health service settings usually faces resistance, we emphasize that CPOE system designers and healthcare decision-makers should continually collect users' feedback about the systems, while not forgetting that it also is necessary to inform the users about the potential benefits involved.
| S-EPMC2809050 | biostudies-literature
Project description:ObjectiveTo study the association between Electronic Health Record (EHR)/Computerized Physician Order Entry (CPOE) provider price display, and domains of healthcare quality (efficiency, effective care, patient centered care, patient safety, equitable care, and timeliness of care).MethodsRandomized and non-randomized studies assessing the relationship between healthcare quality domains and EHR/CPOE provider price display published between 1/1/1980 to 2/1/2018 were included. MEDLINE, Web of Science, and Embase were searched. Assessment of internal validity of the included studies was performed with a modified Downs-Black checklist.ResultsScreening of 1118 abstracts was performed resulting in selection of 41 manuscripts for full length review. A total of 13 studies were included in the final analysis. Thirteen studies reported on efficiency domain, one on effectiveness and one on patient safety. Studies assessing relationship between provider price display and patient centered, equitable and timely care domains were not retrieved. Quality of the studies varied widely (Range 6-12 out of a maximum possible score of 13). Provider price display in electronic health record environment did not consistently influence domains of healthcare quality such as efficiency, effectiveness and patient safety.ConclusionsPublished evidence suggests that price display tools aimed at ordering providers in EHR/CPOE do not influence the efficiency domain of healthcare quality. Scant published evidence suggests that they do not influence the effectiveness and patient safety domains of healthcare quality. Future studies are needed to assess the relationship between provider price display and unexplored domains of healthcare quality (patient centered, equitable, and timely care).RegistrationPROSPERO registration: CRD42018082227.
| S-EPMC7646898 | biostudies-literature