Physician Order Entry System Research Articles

Neonatal Hypoglycemia and the Effects of Dextrose Gel

In 2011, the American Academy of Pediatrics published guidelines for the management of neonatal hypoglycemia. These were guidelines only, because no absolute blood glucose level has been associated with adverse neonatal outcomes. The implementation of these guidelines caused an increased number of admissions to the NICU for neonates with hypoglycemia in the institution. NICU admissions are costly, stressful to the newborn, disrupt parent–newborn bonding, and can negatively impact exclusive breastfeeding rates. In the Sugar Babies Study, the use of dextrose gel was reviewed for treatment of neonatal hypoglycemia in neonates 35 weeks or older gestational age and 48 hours or less of life. The study found a decrease in NICU admission rates, which provided more time for parent–infant bonding, and an increase in 2-week postbirth breastfeeding rates. A new hypoglycemia algorithm would be developed, including the administration of dextrose gel. Dextrose gel would be given to neonates with blood glucose levels less than 45 mg/dl, followed by a feeding of either breast milk or formula. Implementation was preceded by a vigorous educational intervention targeted to reach 85% of the nursing staff. Nurses were given a folder of materials, including a review of how to perform a heel stick; the new hypoglycemia algorithm; the procedure for dextrose administration; and the nursing policy and procedure for hypoglycemia. A demonstration was also provided for the disbursement and administration of dextrose gel. A physician’s order for dextrose gel was added to the Computerized Physician Order Entry (CPOE) system. The dextrose gel was also added to the medication delivery system. Implementation went smoothly, and an immediate effect was noted. Although we did not see a 73% decrease in NICU admissions, as noted in some of the literature, a significant decrease in NICU admissions occurred, with a concomitant improvement of exclusive breastfeeding rates. Dextrose gel administration is a viable alternative to feeding alone for neonates with hypoglycemia, with the results of a reduction in NICU admissions and improvement in exclusive breastfeeding rates. Perinatal nurses can have a significant impact on the NICU admission rates of neonates with hypoglycemia through the administration of dextrose gel in addition to breast milk or formula feeding.

Drug-drug interactions and pharmacists’ interventions among psychiatric patients in outpatient clinics of a teaching hospital in Saudi Arabia

BackgroundLack of recognition of labeled drug-drug interactions (DDIs) is a type of medication error of particular relevance to the treatment of psychiatric patients. Pharmacists are in a position to detect and address potential DDIs. ObjectiveThis study aimed to explore pharmacists’ role in the identification and management of DDIs among psychiatric patients in psychiatric outpatient clinics of a university-affiliated tertiary care hospital in Riyadh, Saudi Arabia. MethodThis study was a retrospective, cross-sectional medical chart review of patients visiting outpatient psychiatric clinics. It utilized medical records of patients who were taking any psychotropic medications and were prescribed at least one additional drug. The hospital Computerized Physician Order Entry system was used to identify DDIs and determine the pharmacists’ interventions. The Beers criteria were applied to detect inappropriate prescribing among older patients. ResultsOn average, the pharmacists intervened in 12 out of 213 (5.6%) cases of major or moderate DDIs. Older age, higher number of prescription medications, the severity of DDIs, and the utilization of lithium and anticoagulants were positively associated with the pharmacist undertaking an action. ConclusionFuture studies should explore the prevalence rate of harmful DDIs among psychiatric patients on a large scale and examine the effectiveness of different pharmacy policies in the detection and management of DDIs.

Educational Targets to Reduce Medication Errors by General Surgery Residents

Hospitalized patients are exposed to more than 1 medication error per day, but there are limited data concerning the factors associated with medication order errors made by general surgery residents. The objective of this study was to identify patterns in medication order errors amongst general surgery residents, which may provide educational targets to reduce medication errors by this population of providers. This study used a retrospective cohort design to review inpatient medication orders placed via a computerized physician order entry system by general surgery residents at a single academic medical center from July 2011 to February 2018. A single large academic medical center located in the Midwest, United States. General surgery residents completing residency between July 2011 and February 2018 and their respective inpatient medication orders. Of 571,811 included medication orders placed by 169 unique general surgery residents, 4.2% (n = 24,177) triggered pharmacist intervention, and 11 (0.001%) resulted in significant near-miss events. Of orders requiring pharmacist intervention, most were either duplicate therapies (n = 8703, 36.1%) or errors in renal dosing (n = 7576, 31.3%). Error rates were higher within pharmaceutical classes ordered less frequently, with the notable exception of antimicrobials and anticoagulants, which accounted for 20.1% (n = 5280) and 13.5% (n = 3270) of all order errors, respectively. In a multivariable model, errors were more likely to occur in the intensive care unit versus other units (OR = 1.21, 95%CI = 1.14-1.29) and in August versus other months (OR = 1.09, 95%CI = 1.01-1.17), but were independent of other resident and order characteristics. This study identified that resident medication order errors are common and are associated with specific therapeutic classes, the beginning of academic years, and intensive care unit patients. These findings represent potential targets for educational interventions and highlight the role of interdisciplinary teams in providing quality surgical care.

Decreasing daily blood work in hospitals: What works and what doesn't.

Recurrent, inappropriate laboratory testing is a costly and wasteful use of healthcare resources. Recognizing this problem, the American Board of Internal Medicine, Canadian Society of Internal Medicine, and the Canadian Association of Pathologist all supported the Choosing Wisely campaign to reduce laboratory investigations in patients who demonstrate clinical and laboratory stability. In this narrative, we review studies looking at a variety of approaches to reduce excessive testing including education, audit and feedback, computerized physician order entry system changes, and forcing functions. Each type of intervention has its own unique advantages and disadvantages, varying in complexity, disruptiveness, effectiveness, and sustainability. Before implementing any quality improvement project, it is important to analyze the local context to identify the root causes for the practice behavior and aim to use the minimal amount of intervention to achieve the desired result. Change is often incremental and will seldom occur with a single intervention or Plan-Do-Study-Act cycle. Garnering the support of opinion leaders and a quality improvement team will help make the process and intervention a success.

Reducing red blood cell folate testing: a case study in utilisation management

Mandatory enrichment of wheat flour in Canada with folic acid since 1998 has caused folate deficiency to be rare. There were 3019 red blood cell (RBC) folate tests performed during...

Effect of changing urine testing orderables and clinician order sets on inpatient urine culture testing: Analysis from a large academic medical center.

To evaluate the impact of changes to urine testing orderables in computerized physician order entry (CPOE) system on urine culturing practices. Retrospective before-and-after study. A 1,250-bed academic tertiary-care referral center. Hospitalized adults who had ≥1 urine culture performed during their stay. The intervention (implemented in April 2017) consisted of notifications to providers, changes to order sets, and inclusion of the new urine culture reflex tests in commonly used order sets. We compared the urine culture rates before the intervention (January 2015 to April 2016) and after the intervention (May 2016 to August 2017), adjusting for temporal trends. During the study period, 18,954 inpatients (median age, 62 years; 68.8% white and 52.3% female) had 24,569 urine cultures ordered. Overall, 6,662 urine cultures (27%) were positive. The urine culturing rate decreased significantly in the postintervention period for any specimen type (38.1 per 1,000 patient days preintervention vs 20.9 per 1,000 patient days postintervention; P < .001), clean catch (30.0 vs 18.7; P < .001) and catheterized urine (7.8 vs 1.9; P < .001). Using an interrupted time series model, urine culture rates decreased for all specimen types (P < .05). Our intervention of changes to order sets and inclusion of the new urine culture reflex tests resulted in a 45% reduction in the urine cultures ordered. CPOE system format plays a vital role in reducing the burden of unnecessary urine cultures and should be implemented in combination with other efforts.

Alternative computer mouse trigger designs in computerized physician order entry (CPOE) system to reduce clinicians’ drop-down menu selection errors

BackgroundExtended daily computer use and overload of clinicians has been associated with a reported increase of prescription error. New mouse activity designs offer alternative strategies to potentially decrease drop-down menu selection error in computerized physician order entry (CPOE) prescription. ObjectiveThis study aimed to evaluate the use of alternative computer mouse trigger designs by clinicians during a prescription task. Data related to mouse activities and prescription error were collected in order to better understand the mouse trigger impact and interaction with level of urgency for physician to prescribe orders in CPOE. Materials and methodsThirty healthy, right-handed clinicians (16 female; 14 male) participated in this study. All participants completed eight prescription trials in which three factors were manipulated: mouse click strategies (single-click vs. double-click), mouse release strategies (down vs. up) and level of urgency (urgent vs. non-urgent). Human performance in terms of drop-down menu selection error was captured for each mouse design. Multiple aspects of participants’ behavior related to prescribing medication were measured in conditions simulating prescription of medication. ResultsThere were significant main effects for mouse click strategies and urgency (F (1, 20) = 11.03, P = 0.002; F (1, 20) = 14.24, P = 0.001), and no significant main effects for mouse release strategies (F (1, 20) = 2.39, P = 0.134) on drop-down menu selection error. A significant interaction, mouse click strategies × urgency, was revealed (F (1, 20) = 5.44, P = 0.027). There was a significant change found in error rate associated with mouse click strategy changes (adjusted OR = 2.38, 95% CI 1.57 to 3.61, P < 0.001) and urgent condition changes (adjusted OR = 0.56, 95% CI 0.37 to 0.83, P = 0.004). ConclusionWhen clinicians input physician orders into CPOE, regardless of mouse release strategy, double clicks were associated with lower error rates than single-click strategy. In urgent situations, double clicks also were associated with a lower error rate compared with single-click strategy. These findings may have wide-ranging applications, and computer engineers may consider adopting a double-click strategy in CPOE to reduce medical error, especially in urgent situations.

Medication prescribing errors: a pre- and post-computerized physician order entry retrospective study.

Background The computerization of prescriptions with a computerized physician order entry contributes to securing the error-freedrug supply, but is not risk-free. Objective: To determine the impact of a computerized physician order entry system on prescribing errors immediately after its implementation and 1year later. Setting The Cardiology and Diabetology Departments at Toulouse University Hospital, France. Method The prescriptions were analysed by pharmacists over three 30-day periods for 3 consecutive years (N: computerization period, N - 1, N + 1). For each identified error, the prescriber was informed by a pharmaceutical intervention. The pharmaceutical interventions were counted and arranged according to the classification by the French Society of Clinical Pharmacy. Their average numbers and clinical impacts were compared for each period using t-tests and Kruskal-Wallis tests. Main outcome measure The average numbers of pharmaceutical interventions. Results In total, 12.1 pharmaceutical interventions per 100 patient days were doneduring the N - 1 period, 14.1 during N and 9.6 during N + 1. Among those, 3.6 (N) and 2.1 (N + 1) were related to thecomputerization itself,and 10.5 (N) and 7.5 (N + 1) were not. The average number of computerization-related pharmaceutical interventions significantly decreased from N to N + 1 (p = 0.04). The average number of classic interventions decreased from N - 1 to N + 1 (p = 0.02). The clinical impacts of the computerization related errors were similar to those ofother errors. Conclusion The implementation of the computerized physician order entry inducedthe appearance of specificcomputerized-related errors, but the number of classic errors decreased. The entry-system relatederrors were not more severe than other errors, andthe number decreased after 1year.

Promoting clinical pharmacy services through advanced medication review in the emergency department

ObjectivesTo determine if an advanced medication review carried out in the emergency department (ED) increases the number of pharmacotherapy recommendations (PR) and the severity of the detected prescribing errors.MethodsWe designed...

Evaluation of nurses’ opinions about computer physician order entry

This research was performed as a descriptive and analytic study to determine the perceptions of the nurses regarding the computerised physician order entry system. The study was conducted with 207 nurses working in four hospitals using this system in Bursa. Sociodemographic data form and the computerised physician order entry system perception scale were used as data collection tool. Obtained data were analysed by statistical methods and nonparametric tests. The scale met an acceptable level of reliability and validity (α = 0.94). There was a statistically significant difference between the groups according to age, position, service and institution, years of institution experience and the period of using the system in terms of scale and sub-dimensions. Finally, it was determined that the nurses perceived the system as positive in spite of some difficulties related to this system. It is suggested that the problems with the system should be solved and training programmes should be organised.Keywords: Nurse, computer physician order entry, medication errors.

Clinical Decision Support Systems for Drug Allergy Checking: Systematic Review.

BackgroundWorldwide, the burden of allergies—in particular, drug allergies—is growing. In the process of prescribing, dispensing, or administering a drug, a medication error may occur and can have adverse consequences; for example, a drug may be given to a patient with a documented allergy to that particular drug. Computerized physician order entry (CPOE) systems with built-in clinical decision support systems (CDSS) have the potential to prevent such medication errors and adverse events.ObjectiveThe aim of this review is to provide a comprehensive overview regarding all aspects of CDSS for drug allergy, including documenting, coding, rule bases, alerts and alert fatigue, and outcome evaluation.MethodsThe Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed as much as possible and searches were conducted in 5 databases using CPOE, CDSS, alerts, and allergic or allergy as keywords. Bias could not be evaluated according to PRISMA guidelines due to the heterogeneity of study types included in the review.ResultsOf the 3160 articles considered, 60 met the inclusion criteria. A further 9 articles were added based on expert opinion, resulting in a total of 69 articles. An interrater agreement of 90.9% with a reliability Κ=.787 (95% CI 0.686-0.888) was reached. Large heterogeneity across study objectives, study designs, study populations, and reported results was found. Several key findings were identified. Evidence of the usefulness of clinical decision support for drug allergies has been documented. Nevertheless, there are some important problems associated with their use. Accurate and structured documenting of information on drug allergies in electronic health records (EHRs) is difficult, as it is often not clear to healthcare providers how and where to document drug allergies. Besides the underreporting of drug allergies, outdated or inaccurate drug allergy information in EHRs poses an important problem. Research on the use of coding terminologies for documenting drug allergies is sparse. There is no generally accepted standard terminology for structured documentation of allergy information. The final key finding is the consistently reported low specificity of drug allergy alerts. Current systems have high alert override rates of up to 90%, leading to alert fatigue. Important challenges remain for increasing the specificity of drug allergy alerts. We found only one study specifically reporting outcomes related to CDSS for drug allergies. It showed that adverse drug events resulting from overridden drug allergy alerts do not occur frequently.ConclusionsAccurate and comprehensive recording of drug allergies is required for good use of CDSS for drug allergy screening. We found considerable variation in the way drug allergy are recorded in EHRs. It remains difficult to reduce drug allergy alert overload while maintaining patient safety as the highest priority. Future research should focus on improving alert specificity, thereby reducing override rates and alert fatigue. Also, the effect on patient outcomes and cost-effectiveness should be evaluated.

Assessing information sources to elucidate diagnostic process errors in radiologic imaging - a human factors framework.

To assess information sources that may elucidate errors related to radiologic diagnostic imaging, quantify the incidence of potential safety events from each source, and quantify the number of steps involved from diagnostic imaging chain and socio-technical factors. This retrospective, Institutional Review Board-approved study was conducted at the ambulatory healthcare facilities associated with a large academic hospital. Five information sources were evaluated: an electronic safety reporting system (ESRS), alert notification for critical result (ANCR) system, picture archive and communication system (PACS)-based quality assurance (QA) tool, imaging peer-review system, and an imaging computerized physician order entry (CPOE) and scheduling system. Data from these sources (January-December 2015 for ESRS, ANCR, QA tool, and the peer-review system; January-October 2016 for the imaging ordering system) were collected to quantify the incidence of potential safety events. Reviewers classified events by the step(s) in the diagnostic process they could elucidate, and their socio-technical factors contributors per the Systems Engineering Initiative for Patient Safety (SEIPS) framework. Potential safety events ranged from 0.5% to 62.1% of events collected from each source. Each of the information sources contributed to elucidating diagnostic process errors in various steps of the diagnostic imaging chain and contributing socio-technical factors, primarily Person, Tasks, and Tools and Technology. Various information sources can differentially inform understanding diagnostic process errors related to radiologic diagnostic imaging. Information sources elucidate errors in various steps within the diagnostic imaging workflow and can provide insight into socio-technical factors that impact patient safety in the diagnostic process.

LO72: A randomized controlled trial of electronic clinical decision support to reduce unnecessary CT imaging for patients with mild traumatic brain injury

Introduction: Utilization of CT imaging has risen dramatically with increases in availability, but without corresponding improvements in patient outcomes for many clinical scenarios. Previous attempts to improve imaging appropriateness have met with limited success, with commonly cited barriers including a lack of confidence in patient outcomes, medicolegal risk, and patient expectations. The objective of this study was to assess the impact of an electronic clinical decision support (CDS) intervention to reduce CT utilization for emergency department (ED) patients with mild traumatic brain injury (MTBI). Methods: This was a cluster-randomized, controlled trial with physicians as the unit of randomization. All emergency physicians (EPs) at 4 urban adult EDs and 1 urgent care center were randomly assigned to receive evidence-based imaging CDS (intervention) or no CDS (control) for patients with MTBI over a 1-year study period. CDS was launched in an external web browser whenever an intervention EP ordered a non-enhanced head CT from the computerized physician order entry (CPOE) system for ED patients CTAS 2-5 with a CEDIS chief complaint of head injury; however, interaction with CDS was voluntary. The CDS tool provided detailed information to physicians about the Canadian CT Head Rule, including patient eligibility, exclusion criteria, risk factors and probability of serious injury, as well as an imaging recommendation (yes/no). CDS recommendations could be printed for the medical record as could educational patient handouts to support physician decision making. The primary outcome was CT utilization for patients with MTBI on the index visit. Secondary outcomes included ED length of stay (LOS), and return visits, CT use, hospital admission and traumatic head injury diagnoses over the next 30-days. This study was REB approved. Results: Physician demographics and baseline CT utilization for MTBI patients were similar among intervention and control EPs during a 2-year pre-intervention period. In the first 8-months following CDS implementation, 102 intervention EPs saw 2,189 eligible patients while 100 control EPs saw 1,707 patients. Intervention EPs voluntarily interacted with CDS on 36.2% of eligible encounters. Head CT utilization was lower among intervention EPs than controls (38.5% vs 45.1%, p&lt;0.0001) as was ED LOS (201 vs 218.5 minutes, p&lt;0.001). There was no difference in 30-day ED return visits, head CT utilization, hospital admission or traumatic head injury diagnoses. Conclusion: In one of the largest RCTs of CDS to date, exposure to CDS was associated with decreased head CT utilization and shorter LOS on the index visit, and no difference in 30-day head CT use, return ED visits or hospital admission. These results suggest that a comprehensive CDS implementation may be able to overcome several barriers to use of decision rules and may contribute to improved clinical decision making and decreased CT utilization.

PMD114 - Impact of the Hitech Act’s Incentive Program on the Adoption of Drug-Drug Interaction Alerts and Electronic Prescribing in the Ambulatory Care Setting

The 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act has allocated billions of dollars as incentives through the meaningful use (MU) program to promote the implementation of electronic health record (EHR) systems nationwide. The use of drug-drug interaction (DDI) alerts, electronic prescribing (eRx), and computerized physician order entry (CPOE) systems integrated into EHR systems has now become mandatory for providers to achieve MU compliance and qualify for financial incentives, that ultimately aimed to reduce medication errors, and improve patient outcomes and adherence. This study examined the extent to which the HITECH Act’s incentive program enhanced the adoption of DDI alerts, eRx and CPOE medication ordering systems. A cross-sectional analysis of 10 years (2006–2015) of the National Ambulatory Medical Care Survey (NAMCS). The data were analyzed at the physician level using weighted analyses. Descriptive statistics for all study variables were calculated. Chi-square test for trend was used to assess the adoption trends. Chi-square test was used for comparison of the adoption proportions before and after initiating the HITECH Act’s incentive program. All analyses were performed using SAS 9.3 at alpha of 0.05. In 2015, 77% of ambulatory care practices had a CPOE medication ordering system that provide DDI alerts and send prescriptions electronically, increasing by 27% since 2011. Trends in adoption of DDI alerts, eRx, and CPOE medication ordering system showed significant increase from 2006 to 2015 (P<.0001). The period after initiating the HITECH Act’s incentive program (2012-2015), showed significant increase in the proportion of the adoption of CPOE medication ordering system (P<.0001) and concurrent use of DDI alerts and eRx functions (P<.0001), compared to prior period (2006-2011). The adoption of CPOE medication ordering systems that provide DDI alerts and send prescriptions electronically have significantly increased after initiating the HITECH Act’s incentive program.

Qualitative exploration of practices to prevent medication errors in neonatal intensive care units: a focus group study.

Medication errors (MEs) in neonates are frequent and associated with increased potential for harm compared with adults. The effect of learning from reported MEs is potentially lacking due to underreporting, lack of feedback and missing actions to improve medication safety. A new approach involving positive recognition of current and future strategies may facilitate greater exploration of how to improve medication safety in neonates. We aimed to explore current and potential future practices to prevent MEs in neonatal intensive care units (NICUs). Focus group interviews of physicians and nurses were conducted at three Danish NICUs. Participants were included if they had at least 1 month of working experience and provided direct patient care. A semistructured interview guide involving three questions was used: (a) how do you feel about discussing prevention of MEs? (b) how do you currently prevent MEs from occurring? and (c) how can we become better at preventing MEs in the future? Content analysis was used to identify themes in the interviews. Participants commented that MEs still occur and that action must be taken to improve medication safety. Current practices to prevent MEs involved technology, procedures, education, skills and hospital pharmacy services. Potential future practices to prevent MEs included customizing the computerized physician order entry systems to support optimal prescribing, standardizing the double-check process, training of calculation skills and teamwork and increased use of hospital pharmacy services. Several current and potential future practices to reduce MEs in NICUs were identified, highlighting the complexity of MEs. Our findings support an interdisciplinary multifaceted intervention involving both technical and nontechnical elements to improve medication safety in NICUs.

Medication Errors Caused by Nurses and Physicians in a Swiss Acute Care Community Hospital: Frequency and Correlation to Nurses’ Reported Workload / Von Pflegefachpersonen und Ärzten/-innen verursachte Medikamentenfehler in einem Schweizer Akutspital: Häufigkeit und Korrelation zur Arbeitsbelastung von Pflegefachpersonen

Abstract Objectives This study was carried out in a Swiss acute care community hospital to investigate the frequency, type, causes and potential clinical consequences of medication errors (MEs) caused by nurses and physicians in all stages of a technology-supported medication process, the relationship between the nurses’ workload and the medication administration errors (MAEs) and their reason for workload. Methods In this descriptive cross-sectional study, a questionnaire, the adapted Medication Error Self Reporting Tool (A-MESRT), was used to identify MEs in all stages of the medication process and record nurses’ self-perceived workload during medication administration. Results A total of 1936 completed A-MESRTs were returned. A total of 751 (38.8%) respondents reported different MEs. The highest number of errors occurred during medication administration (43%), followed by errors during dispensing (34%) and physician ordering errors using a computerised physician order entry (CPOE) system (23%). Of the 768 (100%) handwritten orders, 232 (30.2%) were erroneous. Moreover, the greater the individual nurse’s workload during a shift, the higher was the relative probability of committing an MAE (χ2 = 85.479, df = 1, OR = 2.129, p &lt; 0.001). Furthermore, the three main causes of high or very high workload were revealed: (1) many newly operated patients to monitor; (2) complex multimorbid patients, for example, those with delirium; and (3) patients with complications after surgery. Conclusion The A-MESRT showed that the highest rate of MEs caused by nurses and physicians is in the non-technologically supported steps, demonstrating the potential benefits of a technology-supported medication process. Moreover, this study revealed a statistically significant correlation between nurses’ workload and MAEs.

Complex Drug-Drug-Gene-Disease Interactions Involving Cytochromes P450: Systematic Review of Published Case Reports and Clinical Perspectives.

Drug pharmacokinetics (PK) is influenced by multiple intrinsic and extrinsic factors, among which concomitant medications are responsible for drug-drug interactions (DDIs) that may have a clinical relevance, resulting in adverse drug reactions or reduced efficacy. The addition of intrinsic factors affecting cytochromes P450 (CYPs) activity and/or expression, such as genetic polymorphisms and diseases, may potentiate the impact and clinical relevance of DDIs. In addition, greater variability in drug levels and exposures has been observed when such intrinsic factors are present in addition to concomitant medications perpetrating DDIs. This variability results in poor predictability of DDIs and potentially dramatic clinical consequences. The present review illustrates the issue of complex DDIs using systematically searched published case reports of DDIs involving genetic polymorphisms, renal impairment, cirrhosis, and/or inflammation. Current knowledge on the impact of each of these factors on drug exposure and DDIs is summarized and future perspectives for the management of such complex DDIs in clinical practice are discussed, including the use of advanced Computerized Physician Order Entry (CPOE) systems, the development of model-based dose optimization strategies, and the education of healthcare professionals with respect to personalized medicine.

Information exchange and cooperation with other sectors: Beyond the healthcare

Introduction: Many countries around the world are cooperating with various national and international agencies for Infectious Disease Surveillance. In 2015, there was an outbreak of Middle East Respiratory Syndrome Corona Virus (MERS-CoV) in Korea. An effective way is required to identify and trace those who are suspected to be infected. Short description of practice change implemented: The Drug Utilization Review (DUR) is an online clinical decision support system and provides a real-time drug related alert messaging services for medication orders. Any medication order must be checked with DUR to prevent drug-related medical errors. Aim and theory of change: In order to identify and to trace the individuals who were infected with MERS-CoV and had close-contacts with quickly. Targeted population and stakeholders: Korean population, Healthcare Providers (above of 80,000) and Government ministries such as Korea Immigration Office (KMO), Center for Disease Prevention and Control of Korea (KCDC) and Health Insurance Review and Assessment Service (HIRA). Timeline: June 10, 2015 ~ present. Highlights: The DUR system was effectively used: - To identify and trace infected individuals and those who had close-contacts with them; - To provide rapid infection risk information to medical personnel; - To prevent healthcare associated infections (HAIs); - To improve safety of inpatients and medical personnel; and - To reduce time for epidemiological investigations. Comments on sustainability: The DUR system has been successfully adopted by almost all hospitals and clinics that use computerized physician order entry (CPOE) systems and it will still be useful for surveillance purposes, contributing to the development of integrated medical care. It can be further developed into a national disease monitoring system like as Health Alert Network (HAN). Comments on transferability: Reliable network environment and introduction of electronic medical records are necessary. Conclusions (comprising key findings): The DUR system has been developed to reduce the risk of drug related errors, but it has evolved into a health alert system in the process of overcoming MERS-CoV. This is a good example of the meaningful use of information and information exchange across the healthcare and other sectors.

A Clinical Decision Support Engine Based on a National Medication Repository for the Detection of Potential Duplicate Medications: Design and Evaluation.

BackgroundA computerized physician order entry (CPOE) system combined with a clinical decision support system can reduce duplication of medications and thus adverse drug reactions. However, without infrastructure that supports patients’ integrated medication history across health care facilities nationwide, duplication of medication can still occur. In Taiwan, the National Health Insurance Administration has implemented a national medication repository and Web-based query system known as the PharmaCloud, which allows physicians to access their patients’ medication records prescribed by different health care facilities across Taiwan.ObjectiveThis study aimed to develop a scalable, flexible, and thematic design-based clinical decision support (CDS) engine, which integrates a national medication repository to support CPOE systems in the detection of potential duplication of medication across health care facilities, as well as to analyze its impact on clinical encounters.MethodsA CDS engine was developed that can download patients’ up-to-date medication history from the PharmaCloud and support a CPOE system in the detection of potential duplicate medications. When prescribing a medication order using the CPOE system, a physician receives an alert if there is a potential duplicate medication. To investigate the impact of the CDS engine on clinical encounters in outpatient services, a clinical encounter log was created to collect information about time, prescribed drugs, and physicians’ responses to handling the alerts for each encounter.ResultsThe CDS engine was installed in a teaching affiliate hospital, and the clinical encounter log collected information for 3 months, during which a total of 178,300 prescriptions were prescribed in the outpatient departments. In all, 43,844/178,300 (24.59%) patients signed the PharmaCloud consent form allowing their physicians to access their medication history in the PharmaCloud. The rate of duplicate medication was 5.83% (1843/31,614) of prescriptions. When prescribing using the CDS engine, the median encounter time was 4.3 (IQR 2.3-7.3) min, longer than that without using the CDS engine (median 3.6, IQR 2.0-6.3 min). From the physicians’ responses, we found that 42.06% (1908/4536) of the potential duplicate medications were recognized by the physicians and the medication orders were canceled.ConclusionsThe CDS engine could easily extend functions for detection of adverse drug reactions when more and more electronic health record systems are adopted. Moreover, the CDS engine can retrieve more updated and completed medication histories in the PharmaCloud, so it can have better performance for detection of duplicate medications. Although our CDS engine approach could enhance medication safety, it would make for a longer encounter time. This problem can be mitigated by careful evaluation of adopted solutions for implementation of the CDS engine. The successful key component of a CDS engine is the completeness of the patient’s medication history, thus further research to assess the factors in increasing the PharmaCloud consent rate is required.

Comparison of antibiotic dosing recommendations for neonatal sepsis from established reference sources

Background Incorrect dosing is the most frequent prescribing error in neonatology, with antibiotics being the most frequently prescribed medicines. Computer physician order entry and clinical decision support systems can create consistency contributing to a reduction of medication errors. Although evidence-based dosing recommendations should be included in such systems, the evidence is not always available and subsequently, dosing recommendations mentioned in guidelines and textbooks are often based on expert opinion. Objective To compare dosage recommendations for antibiotics in neonates with sepsis provided by eight commonly used and well-established international reference sources. Setting An expert team from our Dutch tertiary care neonatal intensive care unit selected eight well-established international reference sources. Method Daily doses of the seven most frequently used antibiotics in the treatment of neonatal sepsis, classified by categories for birth weight and gestational age, were identified from eight well-respected reference sources in neonatology/pediatric infectious diseases. Main outcome measure Standardized average daily dosage. Results A substantial variation in dosage recommendations of antibiotics for neonatal sepsis between the reference sources was shown. Dosage recommendations of ampicillin, ceftazidime, meropenem and vancomycin varied more than recommendations for benzylpenicillin, cefotaxime and gentamicin. One reference source showed a larger variation in dosage recommendations in comparison to the average recommended daily dosage, compared to the other reference sources. Conclusion Antibiotic dosage recommendations for neonates with sepsis can be derived from important reference sources and guidelines. Further exploration to overcome variation in dosage recommendations is necessary to obtain standardized dosage regimens.