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Intercepting wrong-patient orders in a computerized provider order entry system.

ABSTRACT: We 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.A 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.Wrong-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.A 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.

SUBMITTER: Green RA

PROVIDER: S-EPMC4447590 | biostudies-literature | 2015 Jun

REPOSITORIES: biostudies-literature

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Intercepting wrong-patient orders in a computerized provider order entry system.

Green Robert A RA Hripcsak George G Salmasian Hojjat H Lazar Eliot J EJ Bostwick Susan B SB Bakken Suzanne R SR Vawdrey David K DK

Annals of emergency medicine 20141218 6

<h4>Study objective</h4>We 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.<h4>Methods</h4>A 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 ...[more]

PMID: 25534652

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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.

Project description:BACKGROUND:Oral thiamine therapy is frequently prescribed to patients at risk for thiamine deficiency despite recommendations emphasizing the need for high doses of parenteral thiamine to reverse brain thiamine deficits. We evaluated the effect of changes to the computerized provider order entry system on the proportion of prescriptions for parenteral thiamine treatment (primary outcome) and dosages prescribed (secondary outcome) within our academic hospital network. METHODS:We obtained data from the pharmacy information system recording thiamine prescribed to inpatients at University Health Network hospitals (Toronto, Ontario) before (Jan. 1, 2010, to Dec. 31, 2011) and after (Nov. 21, 2013, to Apr. 30, 2017) changes to the computerized provider order entry system promoting the use of higher dosages (? 200 mg) of parenterally administered thiamine. Patients receiving thiamine as part of total parenteral nutrition were excluded from analyses, as thiamine prescribing was automated and unlikely to be affected by the intervention. RESULTS:A total of 6105 thiamine prescriptions were written for 2907 patients before the intervention and 12 787 thiamine prescriptions for 8032 patients after the intervention. The proportion of prescriptions for parenteral treatment increased from 55.5% (3386/6105) to 92.5% (11 829/12 787) after the intervention (p < 0.001). Increases in prescribing of parenteral thiamine treatment were sustained or enhanced across the 3.4-year observation period and were realized across all hospital services. Prescriptions for higher dosages of thiamine increased from 1.1% (65/6105) to 61.4% (7845/12 787) after the intervention (p < 0.001). INTERPRETATION:Changes to the computerized provider order entry system were associated with sustained increases in the proportion of prescriptions for high-dose parenteral thiamine therapy. Similar approaches may be leveraged to align prescriber behaviour with well-accepted practice parameters in other areas of medicine.

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.

Project description:Pharmacogenomics (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.The 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.Using 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.Nine 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).Usability 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.

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Intercepting wrong-patient orders in a computerized provider order entry system.

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Intercepting wrong-patient orders in a computerized provider order entry system.

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