Order Entry System Research Articles

ChemoPalRx: Development and implementation of a chemotherapy mobile provider order entry system in a safety net hospital.

73 Background: Computerized provider order entry (CPOE) systems have been shown to enhance the safety and efficiency of prescribing chemotherapy over the handwritten ordering process. However, many institutions lack the financial ability, technological capability, or operational flexibility to invest in and implement such a system. In particular, Olive View-UCLA Medical Center (OVMC), a Los Angeles County safety net hospital, is among these institutions with unique restrictions that preclude the use of chemotherapy CPOE and mandate handwritten orders. Methods: In an effort to bridge the gap for safe chemotherapy prescribing, we aimed to develop and implement an effective, scalable, and sustainable chemotherapy provider order entry solution that was operationally sensitive to institutions without a chemotherapy CPOE. The solution was designed as a mobile application using Xcode, the integrative development environment of Apple Inc., with the Swift programing language. Results: On September 5th, 2018, we launched a free, chemotherapy provider order entry solution on the worldwide Apple App Store – ChemoPalRx. Using ChemoPalRx, providers can search, customize, and print common chemotherapy regimens in prescription format. Along with a reference library of over 120 order set and 450 medications, ChemoPalRx is equipped with the functions to automate dosage calculation, suggest pre-medications and safety parameters, and trigger alerts for missing prescribing information. As a quality improvement initiative, we implemented ChemoPalRx at OVMC. Implementation stages include obtaining administrative buy-in, consulting with multidisciplinary staffs, investing $100 USD for a prescription printer, and encouraging providers to download ChemoPalRx on their own mobile devices. An ongoing prospective cohort study is being conducted to determine ChemoPalRx effectiveness in reducing errors compared to handwritten orders. Conclusions: ChemoPalRx is developed to enhance the safety and efficiency of chemotherapy prescribing. Implementation of this mobile application is feasible in the safety-net hospital setting and has the potential to transform oncology practices globally.

The Effect of Eliminating Intermediate Severity Drug-Drug Interaction Alerts on Overall Medication Alert Burden and Acceptance Rate.

This study aimed to determine the effects of reducing the number of drug-drug interaction (DDI) alerts in an order entry system. Retrospective pre-post analysis at an urban medical center of the rates of medication alerts and alert acceptance during a 5-month period before and 5-month period after the threshold for firing DDI alerts was changed from "intermediate" to "severe." To ensure that we could determine varying response to each alert type, we took an in-depth look at orders generating single alerts. Before the intervention, 241,915 medication orders were placed, of which 25.6% generated one or more medication alerts; 5.3% of the alerts were accepted. During the postintervention period, 245,757 medication orders were placed of which 16.0% generated one or more medication alerts, a 37.5% relative decrease in alert rate (95% confidence interval [CI]: -38.4 to -36.8%), but only a 9.6% absolute decrease (95% CI: -9.4 to -9.9%). 7.4% of orders generating alerts were accepted postintervention, a 39.6% relative increase in acceptance rate (95% CI: 33.2-47.2%), but only a 2.1% absolute increase (95% CI: 1.8-2.4%). When only orders generating a single medication alert were considered, there was a 69.1% relative decrease in the number of orders generating DDI alerts, and an 85.7% relative increase in the acceptance rate (95% CI: 58.6-126.2%), though only a 1.8% absolute increase (95% CI: 1.3-2.3%). Eliminating intermediate severity DDI alerts resulted in a statistically significant decrease in alert burden and increase in the rate of medication alert acceptance, but alert acceptance remained low overall.

Thromboprophylaxis Management in Surgical Patients: The Efficacy of a Protocol in the Electronic Prescription Program.

Venous thromboembolism (VTE) continues to be a problem in surgical patients, but thromboprophylactic measures are not always implemented. This study aimed to evaluate thromboprophylaxis practice in surgical patients at our institution by assessing appropriateness during admission and discharge; 60-day clinical outcomes are analyzed, and finally further interventions are discussed for continued improvement. A cross-sectional, observational study was conducted in patients undergoing orthopedic and abdominal surgical procedures. Initially, the institution protocol was updated and embedded in the Computerized Physician Order Entry system. We then assessed prospective adequacy of thromboprophylaxis as per established in the protocol. The primary endpoint was thromboprophylaxis initiation and, secondarily, the quality of related prescriptions during hospitalization and at discharge. A total of 114 patients were included in the study. According to VTE risk, thromboprophylaxis was initiated in 85.1% of the patients as needed during hospitalization and 94.8% at discharge. The following inadequacies versus the protocol were found: no duration information in the discharge summary (32.5%), incorrect postsurgical administration time of pharmacological prophylaxis (15.8%), omission of mechanical prophylaxis (13.7%), misdosing (9.6%), and omission of pharmacological prophylaxis (2.6%). No VTE events occurred 60 days postdischarge. The electronic protocol was an effective tool, as evidenced by the fact that thromboprophylaxis was initiated in the majority of surgical patients in our institution during hospitalization and at discharge. Still, some aspects leave room for improvement (duration, dosing, and timing), and further measures such as implementation of Electronic Medication Administration Records and new functionalities in the Clinical Decision Support systems are proposed.

185 Impact of Eliminating a Urinalysis With Reflex to Urine Culture on Urine Testing Patterns in the Emergency Department

As antibiotic resistance has increased as a public health threat, attention has focused on interventions aimed at reducing unnecessary antibiotic prescribing. This includes the overtreatment of asymptomatic bacteriuria (ASB), due to unnecessary urine testing with subsequent diagnosis of urinary tract infection (UTI) despite absence of clinical symptoms. With ASB common in some populations, such as older adults, stewardship programs should seek to reduce unnecessary urine testing on asymptomatic patients. A reflex urinalysis (UA) (defined as WBC> 5/hpf = urine culture) order is commonly used in the emergency department (ED) setting due to perceived operational efficiency benefits; however, this can result in unnecessary diagnosis and treatment of UTI. The objective of the study was to evaluate the impact of removing reflex UA from the computerized physician order entry system (CPOE) on overall urine testing patterns in an academic ED. We conducted a retrospective study of all patients who received any urine test in the ED within the six month pre- and post-intervention periods. A one-month washout period was used surrounding reflex UA removal. The intervention consisted of a notification to providers via e-mail who frequently used reflex UA (academic detailing) and removal of reflex UA from personal and ED preference lists and order sets (systems approach). A positive culture was defined as growth of one or more pathogenic organisms at 104 CFU/ml or greater. Patient demographic and urine testing data were extracted from the electronic health record and analyzed using STATA SE15. Primary outcomes were the rates of total cultures and contaminated cultures per 1000 ED visits. Patient safety was assessed by analysis of any missed urine cultures in pyelonephritis or urosepsis cases. Urine culture cost was estimated from the Medicare Clinical Laboratory Fee Schedule. The study included 17,061 patients with 20,029 urine tests (mean age, 45.7 years; 85.0% white; 60.8% female). The six-month average urine culture order rate fell from 63.2 per 1000 ED visits to 35.3 per 1000 post-intervention, a 41% overall reduction (P<0.001). The rate of contaminated cultures was 16.0 per 1000 ED visits before the intervention compared to only 6.9 after (P<0.001) (see Figure). Of those diagnosed with pyelonephritis or sepsis, 72.8% received a urine culture before intervention in contrast to 56.9% after intervention (P<0.001). Cost savings from reduction in urine cultures was estimated to be $10,830. Removal of reflex UA from the CPOE led to significant reductions in the rates of total cultures performed as well as contaminated cultures. However, there was also a significant decrease in urine cultures obtained for conditions where a culture is typically recommended. Ordering systems greatly impact urine testing practices and could have future implications in reducing overtreatment of ASB. Any intervention or change to eliminate reflex UA orders should be accompanied with robust provider education emphasizing the need to separately order urine cultures when indicated.

A systematic analysis of the optimization of computerized physician order entry and clinical decision support systems: A qualitative study in English hospitals.

This article analyzes the range of system optimization activities taking place over an extended period following the implementation of computerized physician order entry and clinical decision support systems. We undertook 207 qualitative semi-structured interviews, 24 rounds of non-participant observations of meetings and system use, and collected 17 organizational documents in five hospitals over three time periods between 2011 and 2016. We developed a systematic analysis of system optimization activities with eight sub-categories grouped into three main categories. This delineates the range of system optimization activities including resolving misalignments between technology and clinical practices, enhancing the adopted system, and improving user capabilities to utilize/further optimize systems. This study highlights the optimization efforts by user organizations adopting multi-user, organization-spanning information technologies. Hospitals must continue to attend to change management for an extended period (up to 5 years post-implementation) and develop a strategy for long-term system optimization including sustained user engagement, training, and broader capability development to ensure smoother and quicker realization of benefits.

The impact of a medication reconciliation programme at geriatric hospital admission: A pre-/postintervention study.

The aim of this study was to improve medication reconciliation and reduce the occurrence of duplicate prescriptions by pharmacists and physicians within 72hours of hospital admission using an intelligent prescription system combined with the National Health Insurance PharmaCloud system to integrate the database with the medical institution computerized physician order entry (CPOE) system. This 2-year intervention study was implemented in the geriatric ward of a hospital in Taiwan. We developed an integrated CPOE system linked with the PharmaCloud database and established an electronic platform for coordinated communication with all healthcare professionals. Patients provided written informed consent to access their PharmaCloud records. We compared the intervention effectiveness within 72hours of admission for improvement in pharmacist medication reconciliation, increased at-home medications documentation and decreased costs from duplicated at-home prescriptions. The medication reconciliation rate within 72hours of admission increased from 44.0% preintervention to 86.8% postintervention (relative risk=1.97, 95% confidence interval [CI]: 1.69-2.31; P<.001). The monthly average of patients who brought and took home medications documented in the CPOE system during hospitalization increased by 7.54 (95% CI 5.58-20.49, P=.22). The monthly average of home medications documented increased by 102.52 (95% CI 38.44-166.60; P=.01). Savings on the monthly average prescription expenditures of at-home medication increased by US$ 2,795.52 (95% CI US$1310.41-4280.63; P<.01). Integrating medication data from PharmaCloud to the hospital's medical chart system improved pharmacist medication reconciliation, which decreased duplicated medications and reduced in-hospital medication costs.

Surgeon Burnout: Defining, Identifying, and Addressing the New Reality.

Surgeon wellness is a multidimensional commitment that encompasses occupational, mental, physical, emotional, and social domains. Loss of professional control, autonomy, and flexibility; inefficient processes; disjointed workplace relationships and goals; excessive administrative burdens; poor work-life balance; and frustrations with medical record and order entry systems have all been associated with burnout. Described as a syndrome of emotional exhaustion, depersonalization, and loss of a sense of personal accomplishment, burnout can have myriad untoward consequences. The strong link between surgeons' personal and professional identities can lead to a perfect storm of burnout, depression, compromised patient safety and quality of care, physician job loss and career dissatisfaction, substance abuse, damage to personal relationships, and suicide. The alarming scope of this problem cannot be confined to a single specialty or practice setting and is expected to increase without much needed changes to surgeon work practices and work environments. A heightened focus on wellness in the workplace with attention to improving workflow, scheduling, collaboration, and resource allocation is a welcome step taken by several institutions and championed by professional societies. Much more research is needed to reliably gauge the overall effectiveness of these approaches, further address the nuances of burnout as it applies specifically to surgeons, and ensure that members of the surgical workforce remain at their peak throughout the duration of their careers.

The negotiated order and electronic patient records: A sociomaterial perspective

In this article, we consider how the notion of the negotiated order can be reinterpreted by drawing on ideas from sociomateriality. We argue that the negotiated order is an ongoing accomplishment in which a heterogeneous set of situated sociomaterial practices (or actors) are implicated. To do this, we draw upon an in-depth study of the use of a computerised physician order entry system in a hospital in Saudi Arabia. We explore how a computerised physician order entry system, as a new sociomaterial actor, performatively repositions the actors involved and hence offers the conditions of possibility for medical work practices to be renegotiated. We show that it is often contingent, mundane, situated sociomaterial practices that enact the conditions under which the negotiated order becomes re-established in terms of division of labour, legitimacy, collaboration, and social capital. We argue that as the social and material are co-constitutive, or intra-actional, it makes more sense to talk about the negotiated intra-actional order rather than the negotiated order. Importantly, such a change in conceptual vocabulary reveals the empirical and ontological issues at stake; essential for a more nuanced understanding of change/becoming.

Preventing medication errors involving different formulations of cyclosporine

Patients who receive solid organ or allogeneic hematopoietic stem cell transplants are required to take long-term immunosuppressant drugs to prevent rejection and graft-versus-host disease. The drug and dosage selection of immunosuppressants is usually individualized for the patient based on the type of transplant, target blood level, body weight, drug–drug interactions, and the risk of rejection or toxicity. The complexity of the selection process can introduce the risk for errors. Almost 20 years ago, ISMP alerted health care practitioners about Sandimmune (cyclosporine capsules and oral solution) and how this nonmodified form of the drug has decreased bioavailability compared with Neoral or Gengraf (cyclosporine [modified] capsules and oral solution). At the time, a survey by Novartis identified that 24% of prescriptions failed to specify which form of the drug should be dispensed, and only 22% of these prescriptions were clarified. We mention this because, 20 years later, we are still receiving reports of patients receiving Sandimmune when the prescriber’s preference was for a cyclosporine (modified) oral formulation. For example, three patients received Sandimmune instead of the more appropriate form of the drug, Neoral or Gengraf. In another case, during medication reconciliation, a nurse documented that a hospitalized patient was taking cyclosporine but did not verify the brand name to determine the form of the drug. The patient’s physician prescribed Sandimmune, and the patient received a dose before a pharmacy technician discovered that the patient had recently filled a prescription for Gengraf. Many transplant centers use oral solution formulations of immunosuppressant agents to allow greater flexibility in dosage adjustments, especially for pediatric patients. In one case, a 10-fold overdose of cyclosporine (modified) oral solution was administered to a child. The physician prescribed 0.5 mL (50 mg), and the pharmacy dispensed a sealed package of the medication (100 mg/mL), which contained a 5-mL oral syringe provided by the manufacturer that was calibrated in 1-mL increments, with hash marks between each milliliter. The child’s parent administered 5 mL (500 mg) instead of 0.5 mL to the child for several days. Since immunosuppressant agents have significant interpatient dosing variability, dosage delivery devices need to be selected specifically for each patient, and one size does not fit all. In this case, the 5-mL syringe size was significantly larger than each intended dose and did not facilitate accurate measurement and delivery of the prescribed dose. If the pharmacy that dispensed the cyclosporine had used a teach-back method during counseling, for instance, the dosing error might have been avoided. Cyclosporine and cyclosporine (modified) products are not interchangeable. Blood levels must be monitored to prevent serious consequences if a transplant patient receives the wrong formulation. Consider the following recommendations to reduce the risk of errors:▪Prescribers should indicate the brand name, and pharmacists should clarify prescriptions for cyclosporine.▪Order entry systems should clearly display these different forms of the drug, and a hard stop should force verification of the correct drug form during prescribing.▪Upon dispensing an oral solution, pharmacists should evaluate the appropriateness of the dosage delivery device included in the package. To improve accuracy and safety, select the dosage delivery device that will work best for the patient and his or her specific dose. A 2017 study found that providing dosing devices that closely matched the prescribed volume per dose offered the greatest reduction of errors.1.Yin H.S. et al.Pediatrics. 2017; 140 (e20163237)Google Scholar▪Health professionals, using a teach-back method, should ask patients and caregivers to show them how they will withdraw and measure oral liquid medications using their dosage delivery device.

Medication stewardship using computerized clinical decision support: A case study on intravenous immunoglobulins.

BackgroundHealthcare delivery organizations face increasing pressure to manage the use of medications in terms of safety, waste reduction, and cost containment.ObjectiveTo describe a computerized provider order entry (CPOE) system intervention to optimize use of a commonly ordered, high‐cost therapeutic: intravenous immune globulin (IVIG).DesignDescription of IVIG order configuration, medication use patterns, and subsequent order set configuration development in a CPOE system.MeasurementsIVIG orders were extracted from the CPOE system before and after the implementation of a specialty orderset to determine the indications for use, dosing, and duration of therapy. Orders were compared to a theoretical dosing schedule created from published evidence and data from a prior medication use evaluation.ResultsDuring 36 months before the implementation of the IVIG order set, 1965 IVIG orders were reviewed. The prescribed IVIG dose varied considerably from the expected dose (mean = −1.8, range = −4.9‐1.5). In the 27 months after order set implementation, 848 IVIG orders were reviewed. The prescribed IVIG dose was closer to the expected dose (mean = −1.2, range = −3.9‐2.6, P < .0001).ConclusionsOrder configuration processes are cumbersome and time‐consuming, but can be streamlined to enhance a medication’s usage in the healthcare system. A better understanding of institution‐specific ordering patterns may facilitate more efficient and effective order configuration and optimize drug use.

Identifying low value pathology test ordering in hospitalised patients: a retrospective cohort study across two hospitals

The push to identify low value care has led to scrutiny of pathology test re-ordering. The objective of this study was to identify the patterns of ordering pathology tests among inpatients in teaching hospitals and model strategies to reduce unnecessary testing. This was a retrospective cohort study of all adult medical and surgical inpatients admitted to one major teaching hospital and one rural hospital in the same health district over 2 years. Obstetric, gynaecological, intensive care, elective/day procedures and dialysis admissions were excluded. Orders for electrolytes, urea and creatinine (EUC), full blood count (FBC), thyroid stimulating hormone (TSH), glycated haemoglobin (HbA1c), vitamin D, and troponin, date of order, and value of the resulting test, were obtained from a health district data warehouse. Pathology results were mapped to each inpatient day. EUC and FBC constituted over 90% of all inpatient pathology requests for these six tests. Between 40-45% of inpatients had EUC and/or FBC performed daily. After the first couple of tests, the retest interval was consistently around 24 hours, regardless of the previous value of the test, consistent with a culture of routine ordering. This was less pronounced in the rural hospital compared to the urban teaching hospital. Lockouts (applied when previous tests normal) or minimum retest intervals (applied to previously normal and abnormal tests) of various lengths were tested on the data to find optimal combinations that reduced unnecessary tests without missing too many very abnormal tests. A lockout of 48 hours for EUC and 48 hour lockout combined with a 12 hour minimum retest interval for FBC appear optimal to reduce over ordering and could save approximately AU$400/inpatient bed per year at a single teaching hospital. There is evidence of low value re-ordering of EUC and FBC pathology tests. Implementation of a computerised physician order entry system with inbuilt prompts to restrict unnecessary re-ordering of pathology tests may be a practical solution.

A cross-sectional study: medication safety among cancer in-patients in tertiary care hospitals in KPK, Pakistan

BackgroundMedication safety in cancer patients receiving complex medication regimens is an important problem in various settings. Medication related events, interceptions and interventions are not well described in this area. We intended to study incidence, types, settings and stages involved, root cause analysis, medication classes involved and the level of harm cause by medication errors in two hospitals providing oncology services comparatively. The severity of incidents and interventions are studied.MethodsIt was a prospective cross sectional study among cancer in-patients of two tertiary care hospitals of KPK. Scale by NCC-MERP was used for evaluation of all medication related incidents. The data obtained was analyzed by IBM SPSS statistics 22 with 95% confidence interval and used the same for other descriptive statistics.ResultsAll medication orders were reviewed at both sites (Computerized Prescription Order Entry and HWP systems). Potential ADEs incidence was found high at site 2 (97.5%) while medication errors without harm was high at site 1 (97.5%). Most events occur at prescribing level 87.6 and 81.7% at both sites 1 and 2. Types highly reported involved improper dose 31.4 and 15.5%, monitoring error 14.6 and 15.2% at site 1 and 2. Medications involved in these incidents were antibiotics 44 and 12.7%, antiemetic 7.5 and 15.8% and antineoplastic 2.9 and 9.4% at site 1 and 2. Severity of 3.6 and 36.5% incidents had potential to cause harm at site 1 and 2. Root causes were human factors 62.6 and 72.3%, drug selection 33.6 and 38.8%, and dose selection 39.6 and 15.3% at sites 1 and 2. Contributing factors including staff training 33.6 and 24.3%, system for covering patient care 14.9 and 36.6%, communication system 2.4 and 20.3%, interruptions 9.7 and 7.3% and others 78.8 and 68.6% were highly reported. Preventability of medication errors was 99% at both sites. Intervention was taken in 90.5% events at site 1 (CPOE system) while the incidence lowest at site 2 (HWP system).ConclusionMedication related events are high among cancer in-patients at the site lacking updated electronic system for medication prescribing. Proper training about medication safety, reporting and interventions are required.

Effect of Electronic Prescribing Strategies on Medication Error and Harm in Hospital: a Systematic Review and Meta-analysis.

Computerized physician order entry and clinical decision support systems are electronic prescribing strategies that are increasingly used to improve patient safety. Previous reviews show limited effect on patient outcomes. Our objective was to assess the impact of electronic prescribing strategies on medication errors and patient harm in hospitalized patients. MEDLINE, EMBASE, CENTRAL, and CINAHL were searched from January 2007 to January 2018. We included prospective studies that compared hospital-based electronic prescribing strategies with control, and reported on medication error or patient harm. Data were abstracted by two reviewers and pooled using random effects model. Study quality was assessed using the Effective Practice and Organisation of Care and evidence quality was assessed using Grading of Recommendations Assessment, Development, and Evaluation. Thirty-eight studies were included; comprised of 11 randomized control trials and 27 non-randomized interventional studies. Electronic prescribing strategies reduced medication errors (RR 0.24 (95% CI 0.13, 0.46), I2 98%, n = 11) and dosing errors (RR 0.17 (95% CI 0.08, 0.38), I2 96%, n = 9), with both risk ratios significantly affected by advancing year of publication. There was a significant effect of electronic prescribing strategies on adverse drug events (ADEs) (RR 0.52 (95% CI 0.40, 0.68), I2 0%, n = 2), but not on preventable ADEs (RR 0.55 (95% CI 0.30, 1.01), I2 78%, n = 3), hypoglycemia (RR 1.03 (95% CI 0.62-1.70), I2 28%, n = 7), length of stay (MD - 0.18 (95% - 1.42, 1.05), I2 94%, n = 7), or mortality (RR 0.97 (95% CI 0.79, 1.19), I2 74%, n = 9). The quality of evidence was rated very low. Electronic prescribing strategies decrease medication errors and adverse drug events, but had no effect on other patient outcomes. Conservative interpretations of these findings are supported by significant heterogeneity and the preponderance of low-quality studies.

Integration of a Commercial Barcode-Assisted Medication Dispensing System in a Teaching Hospital

A commercial barcode-assisted medication administration (BCMA) system was integrated to secure the medication process and particularly the dispensing stage by technicians and the administration stage with nurses. We aimed to assess the impact of this system on medication dispensing errors and barriers encountered during integration process. We conducted a controlled randomized study in a teaching hospital, during dispensing process at the pharmacy department. Four wards were randomized in the experimental group and control group, with two wards using the system during 3 days with dedicated pharmacy technicians. The system was a closed loop system without information return to the computerized physician order entry system. The two dedicated technicians had a 1-week training session. Observations were performed by one observer among the four potential observers previously trained. The main outcomes assessed were dispensing error rates and the identification of barriers encountered to expose lessons learned from this study. There was no difference between the dispensing error rate of the control and experimental groups (7.9% for both, p = 0.927). We identified 10 barriers to pharmacy barcode-assisted system technology deployment. They concerned technical (problems with semantic interoperability interfaces, bad user interface, false errors generated, lack of barcodes), structural (poor integration with local information technology), work force (short staff training period, insufficient workforce), and strategic issues (system performance problems, insufficient budget). This study highlights the difficulties encountered in integrating a commercial system in current hospital information systems. Several issues need to be taken into consideration before the integration of a commercial barcode-assisted system in a teaching hospital. In our experience, interoperability of this system with the electronic health record is the key for the success of this process with an entire closed loop system from prescription to administration. BCMA system at the dispensing process remains essential to purchase securing medication administration process.

Association of a Multifaceted Intervention With Ordering of Unnecessary Laboratory Tests Among Caregivers in Internal Medicine Departments

Inappropriate use of laboratory testing is a challenging problem. Estimated overuse rates of approximately 20% have been reported. Effective, sustainable solutions to stimulate optimal use are needed. To determine the association of a multifaceted intervention with laboratory test volume. A before-after quality improvement study was performed between August 1, 2016, and April 30, 2018, in the internal medicine departments of 4 teaching hospitals in the Netherlands. Data on laboratory order volumes from 19 comparable hospitals were used as controls. The participants were clinicians ordering laboratory tests. The intervention included creating awareness through education and feedback, intensified supervision of residents, and changes in order entry systems. Interventions were performed by local project teams and guided by a central project team during a 6-month period. Sustainability was investigated during an 8-month follow-up period. The primary outcome was the change in slope for laboratory test volume. Secondary outcomes were change in slope for laboratory expenditure, order volumes and expenditure for other diagnostic procedures, and clinical outcomes. Data were collected on duration of hospital stay, rate of repeated outpatient visits, 30-day readmission rate, and rate of unexpected prolonged duration of hospital stay for patients admitted for pneumonia. The numbers of internists and residents ordering tests in hospitals 1 to 4 were 16 and 30, 18 and 20, 13 and 17, and 21 and 60, respectively. Statistically significant changes in slope for laboratory test volume per patient contact were found at hospital 1 (change in slope, -1.55; 95% CI, -1.98 to -1.11; P < .001), hospital 3 (change in slope, -0.74; 95% CI, -1.42 to -0.07; P = .03), and hospital 4 (change in slope, -2.18; 95% CI, -3.27 to -1.08; P < .001). At hospital 2, the change in slope was not statistically significant (-0.34; 95% CI, -2.27 to 1.58; P = .73). Laboratory test volume per patient contact decreased by 11.4%, whereas the volume increased by 2.4% in 19 comparable hospitals. Statistically significant changes in slopes for laboratory costs and volumes and costs for other diagnostic procedures were also observed. Clinical outcomes were not associated with negative changes. Important facilitators were education, continuous attention for overuse, feedback, and residents' involvement. Important barriers were difficulties in data retrieval, difficulty in incorporation of principles in daily practice, and high resident turnover. A set of interventions aimed at changing caregivers' mindset was associated with a reduction in the laboratory test volume in all departments, whereas the volume increased in comparable hospitals in the Netherlands. This study provides a framework for nationwide implementation of interventions to reduce unnecessary laboratory testing.

Pharmacists' role in antimicrobial stewardship and relationship with antibiotic consumption in hospitals: An observational multicentre study.

Antimicrobial stewardship (AMS) teams around the world include pharmacists; however, their impact is relatively unknown. This study aimed to explore the relationship between pharmacists' actions and antibiotic consumption. Hospital pharmacists involved in the French antibiotic consumption surveillance network (ATB-Raisin) were invited to participate in a retrospective observational multicentre study. Collected data were: the previous year's (2016) antibiotic consumption expressed in daily defined dose per 1000 patient-days; AMS measures, including pharmacist-specific actions; and use of a computerised prescription order entry (CPOE) system. Associations between antibiotic consumption and AMS measures were assessed by linear regression, after adjustment for hospital activities. Annual data for 2016 from 77 hospitals (7260000 bed-days in 24000 beds) were analysed. Pharmacists were involved in AMS programs in 73% of hospitals, and were the antibiotic advisor in 25%. Pharmaceutical review of prescriptions was organised in almost all hospitals (97%). The univariable analysis identified five measures associated with lower overall antibiotic consumption: CPOE use (if >80% of prescriptions or 100%), pharmaceutical review (if >80% of beds or 100%) and the antibiotic advisor being a pharmacist (P=0.04, P=0.004 and P=0.003, respectively). In the multivariable analysis, two explanatory variables were significantly and independently associated with a lower overall antibiotic consumption: the antibiotic advisor being a pharmacist and a pharmaceutical review covering all beds (-19.9% [-31.6%; -8.1%], P=0.002 and -18.3% [-34.0%; -2.6%], P=0.03, respectively). Antibiotic consumption was lower when the antibiotic advisor was a pharmacist and when the pharmaceutical team reviewed all prescriptions. These results highlight that actions initiated by pharmacists have a positive impact and should be supported.

To Computerised Provider Order Entry system: A comparison of ECF, HFACS, STAMP and AcciMap approaches.

Different accident analytical approaches have been utilised in safety-critical industries for analysing accidents and formulating safety recommendations. This study presents a 'health informatics' case incident of a patient adversely affected due to a medication dosing error resulting from a combination of contributing factors including those relating to the Computerised Order Provider Entry System. A comparative study was carried out using selected accident analytical approaches: Human Factors and Classification System, System-Theoretic Accident Modelling and Processes and Accident Modelling. Each resulting output was compared using the model characteristic criteria developed by Underwood and Waterson. Safety recommendations developed based on the outputs from the models/methods were also compared for any similar findings. It was acknowledged that while accident models incorporating 'systems thinking' can prove to be beneficial for healthcare in providing insight on systemic factors, there is a need for improving the reliability and validity of these models. This particularly applies to Rasmussen's Accident Modelling approach to be considered useful in the healthcare domain.

No refills: The durable impact of a multifaceted effort by surgical trainees to minimize the prescription of postoperative opioids

BackgroundSurgeons have the opportunity to help offset the opioid epidemic by leading with practice changes. We sought to decrease the amount of opioid prescribed postoperatively through a multifaceted program. MethodsA multipronged program was introduced in our hospital system, which included resident education on prescribing for postoperative analgesia, a change in the default number of opioid pills in an electronic medication order entry system, and the distribution of a guideline card of recommended postoperative opioid prescription amounts. The amount of opioid prescribed postoperatively between January 2016 and August 2018 was collected for the 10 most common short-stay (<48 hours) general surgery procedures. The 6 months prior to any intervention (pre-intervention) was compared to the last 6 months of data collection (post-intervention). ResultsIn the study, 14,007 operations were captured, including 2,530 pre-intervention and 2,715 post-intervention. The average amount of postoperative opioid prescribed in the pre-intervention period was 207.1 morphine milligram equivalents; post-interventions, the average amount declined to 104.6 morphine milligram equivalents (P < .01). The opioid refill rate remained the same (3.3% pre-intervention vs 3.1% post-intervention, P = .76). ConclusionA comprehensive program to eliminate the over-prescription of opioids decreased the amount of opioid prescribed by half, without a concurrent increase in opioid refills, demonstrating that simple measures can be used to deliver sustained and reproducible improvements in offering source control in the opioid epidemic.

How often do prescribers include indications in drug orders? Analysis of 4 million outpatient prescriptions.

To examine the extent to which outpatient clinicians currently document drug indications in prescription instructions. Free-text sigs were extracted from all outpatient prescriptions generated by the computerized prescriber order entry system of a major academic institution during a 5-year period. Natural language processing was used to identify drug indications. The data set was analyzed to determine the rates at which prescribers included indications. It was stratified by provider specialty, drug class, and specific medications, to determine how often these indications were in prescriptions for as-needed (PRN) versus non-PRN medications. During the study period, 4,356,086 prescriptions were ordered. Indications were included in 322,961 orders (7.41%). From these orders, 249,262 indications (77.18%) were written for PRN orders. Although internal medicine prescribers generated the highest number of medication orders, they included indications in only 6.26% of their prescriptions, whereas orthopedic surgery providers had the highest rate of documenting indications (33.41%). Pain was the most common indication, accounting for 30.35% of all documented indications. The drug class with the highest number of sigs-containing indications was narcotic analgesics. Non-PRN chronic medication prescriptions rarely included the indication. Prescribers rarely included drug indications in electronic free-text prescription instructions, and, when they did, it was mostly for PRN uses such as pain.

Effective stakeholder engagement: design and implementation of a clinical trial (SWOG S1415CD) to improve cancer care

BackgroundThe Fred Hutchinson Cancer Research Center has engaged an External Stakeholder Advisory Group (ESAG) in the planning and implementation of the TrACER Study (S1415CD), a five-year pragmatic clinical trial assessing the effectiveness of a guideline-based colony stimulating factor standing order intervention. The trial is being conducted by SWOG through the National Cancer Institute Community Oncology Research Program in 45 clinics. The ESAG includes ten patient partners, two payers, two pharmacists, two guideline experts, four providers and one medical ethicist. This manuscript describes the ESAG’s role and impact on the trial.MethodsDuring early trial development, the research team assembled the ESAG to inform plans for each phase of the trial. ESAG members provide feedback and engage in problem solving to improve trial implementation. Each year, members participate in one in-person meeting, web conferences and targeted email discussion. Additionally, they complete a survey that assesses their satisfaction with communication and collaboration. The research team collected and reviewed stakeholder input from 2014 to 2018 for impact on the trial.ResultsThe ESAG has informed trial design, implementation and dissemination planning. The group advised the trial’s endpoints, regimen list and development of cohort and usual care arms. Based on ESAG input, the research team enhanced patient surveys and added pharmacy-related questions to the component application to assess order entry systems. ESAG patient partners collaborated with the research team to develop a patient brochure and study summary for clinic staff. In addition to identifying recruitment strategies and patient-oriented platforms for publicly sharing results, ESAG members participated as co-authors on this manuscript and a conference poster presentation highlighting stakeholder influence on the trial. The annual satisfaction survey results suggest that ESAG members were satisfied with the methods, frequency and target areas of their engagement in the trial during project years 1–3.ConclusionsDiverse stakeholder engagement has been essential in optimizing the design, implementation and planned dissemination of the TrACER Study. The lessons described in the manuscript may assist others to effectively partner with stakeholders on clinical research.