Evaluation of a Computerized Prescriber Order Entry Program for Antibiotics in the Neonatal Intensiv

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Evaluation of a Computerized Prescriber Order
Entry Program for Antibiotics in the Neonatal
Intensive Care Unit

• Lizbeth Hansen, Pharm.D.
• Pharmacy Practice Resident
• Preceptors Sandra Garner, Pharm.D.
• Toby Cox Pharm.D.

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Pediatric Medication Errors

• Childrens risk for potential adverse drug events
  (ADEs) nearly triple those in adult patients
• Rate is significantly higher neonates
• 28 of potential ADEs involved anti-infective
  drugs

Kaushal R. Medication errors and adverse drug
events in pediatric inpatients. JAMA.
20012852114-2120.
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Pediatric Medication Errors

• ADEs by stage of error
• Physician ordering 74
• Transcribing 10
• Nurse administration 13
• Pharmacy dispensing lt1
• Patient monitoring lt1
• 64.4 of medication errors considered preventable
  with computerized physician order entry (CPOE)
• 43 of potentially harmful errors

Kaushal R. Medication errors and adverse drug
events in pediatric inpatients. JAMA.
20012852114-2120. Bobb A. The epidemiology of
prescribing errors. Arch Int Med.
2004164785-792.
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Purpose

• Determine effect of CPOE program on the rate of
  prescribing errors for antibiotics in the NICU
  for late onset neonatal sepsis

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Late Onset Neonatal Sepsis

• Onset beyond 72 hours of life
• Organisms responsible for bloodstream infections
• Coagulase-negative staphylococci 48.3
• Enterococci 15.5
• Non-albicans fungi 10.3
• Candida albicans 6.9
• Pseudomonas aeruginosa 5.2
• Serratia marcescens 3.4
• Escherichia coli 3.4
• Staphylococcus Aureus 3.4
• Klebsiella pneumoniae 1.7
• Other bacteria 1.7

Sohn AH. Prevalence of nosocomial infections in
neonatal intensive care unit patients Results
from the first national point-prevalence
survey. J Pediatr. 2001139821-827.
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Late Onset Neonatal Sepsis

• Risk factors for acquisition of infections in
  NICU
• Gestational age
• Postnatal age
• Birth weight
• Total parenteral nutrition
• Central venous catheter use
• Mechanical ventilation

Sohn AH. Prevalence of nosocomial infections in
neonatal intensive care unit patients Results
from the first national point-prevalence
survey. J Pediatr. 2001139821-827.
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Emperic Treatment of LOS

• Vancomycin Piperacillin/tazobactam
• Hemodynamically unstable
• Central line 10 days
• Nafcillin Gentamicin
• Hemodynamically stable
• Central line lt 10 days
• Add antifungal
• Birth weight 1,000g
• Thrombocytopenia or significant drop in platelet
  count
• Frequent or prolonged antibiotic use

MUSC Recommendation of Task Force Evaluation and
Treatment of Nosocomial Sepsis. Revised 6/28/04.
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Neonatal Late Onset Sepsis Evaluation Orders
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Neonatal Late Onset Sepsis Evaluation Orders
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Methods
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Methods

• Orders assessed for
• MUSC required elements of pediatric orders
  Patient name, date of birth, medical record
  number, date and time, weight, medication name,
  dose, dosage units, dosage calculation (based on
  mg/kg), route, frequency/interval, signature and
  pager, no prohibited abbreviations
• Appropriate dose, route, schedule, choice of
  antibiotics
• Drug-drug or drug-disease state interaction,
  contraindications

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Pre-CPOE Results
2.6 orders were missing critical data
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Pre-CPOE Results
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Pre-CPOE Results
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Limitations

• Potential for missing orders
• Always potential for pharmacist intervention
• Classification of medication errors requires
  clinical judgment
• Prescribers aware of study progress
• May not be generalizable to non-academic hospital
• Some debate in literature
• Late onset neonate sepsis 48 hr vs 72 hr of life
• The choice of emperic antimicrobials

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Conclusions

• Significant rate of medication errors in our NICU
• Missing information
• Error prone schedule abbreviation
• Not ordered STAT

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Questions?