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The Role of Health Information Technology in Medication Safety Wednesday, April 25, 2007 12:00 1:00

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Title: The Role of Health Information Technology in Medication Safety Wednesday, April 25, 2007 12:00 1:00


1
The Role of Health Information Technology in
Medication SafetyWednesday, April 25,
20071200 100 p.m. EDT
2
  • Moderator
  • Paul Sharek, MD, MPH, FAAP
  • Assistant Professor of Pediatrics, Stanford
    School of Medicine
  • Medical Director of Quality Management
  • Chief Clinical Patient Safety Officer
  • Lucile Packard Childrens Hospital
  • Palo Alto, California

3
This activity was funded through an educational
grant from the Physicians Foundation for Health
Systems Excellence.
4
Disclosure of Financial Relationships and
Resolution of Conflicts of Interest for AAP CME
Activities Grid
  • The AAP CME program aims to develop, maintain,
    and increase the competency, skills, and
    professional performance of pediatric healthcare
    professionals by providing high quality,
    relevant, accessible and cost-effective
    educational experiences. The AAP CME program
    provides activities to meet the participants
    identified education needs and to support their
    lifelong learning towards a goal of improving
    care for children and families (AAP CME Program
    Mission Statement, August 2004).
  • The AAP recognizes that there are a variety of
    financial relationships between individuals and
    commercial interests that require review to
    identify possible conflicts of interest in a CME
    activity. The AAP Policy on Disclosure of
    Financial Relationships and Resolution of
    Conflicts of Interest for AAP CME Activities is
    designed to ensure quality, objective, balanced,
    and scientifically rigorous AAP CME activities by
    identifying and resolving all potential conflicts
    of interest prior to the confirmation of service
    of those in a position to influence and/or
    control CME content. The AAP has taken steps to
    resolve any potential conflicts of interest.
  • All AAP CME activities will strictly adhere to
    the 2004 Updated Accreditation Council for
    Continuing Medical Education (ACCME) Standards
    for Commercial Support Standards to Ensure the
    Independence of CME Activities. In accordance
    with these Standards, the following decisions
    will be made free of the control of a commercial
    interest identification of CME needs,
    determination of educational objectives,
    selection and presentation of content, selection
    of all persons and organizations that will be in
    a position to control the content, selection of
    educational methods, and evaluation of the CME
    activity.
  • The purpose of this policy is to ensure all
    potential conflicts of interest are identified
    and mechanisms to resolve them prior to the CME
    activity are implemented in ways that are
    consistent with the public good. The AAP is
    committed to providing learners with commercially
    unbiased CME activities.

5
DISCLOSURES
6
DISCLOSURES
7
DISCLOSURES
8
CME CREDIT
  • The American Academy of Pediatrics (AAP) is
    accredited by the Accreditation Council for
    Continuing Medical Education to provide
    continuing medical education for physicians.
  •  
  • The AAP designates this educational activity for
    a maximum of 1.0 AMA PRA Category 1 Credit.
    Physicians should only claim credit commensurate
    with the extent of their participation in the
    activity.
  •  
  • This activity is acceptable for up to 1.0 AAP
    credit. This credit can be applied toward the
    AAP CME/CPD Award available to Fellows and
    Candidate Fellows of the American Academy of
    Pediatrics.

9
OTHER CREDIT
  • This webinar is approved by the National
    Association of Pediatric Nurse Practitioners
    (NAPNAP) for 1.2 NAPNAP contact hours of which
    0.3 contain pharmacology (Rx) content. The AAP
    is designated as Agency 17. Upon completion of
    the program, each participant desiring NAPNAP
    contact hours should send a completed certificate
    of attendance, along with the required recording
    fee (10 for NAPNAP members, 15 for nonmembers),
    to the NAPNAP National Office at 20 Brace Road,
    Suite 200, Cherry Hill, NJ 08034-2633.
  •  
  • The American Academy of Physician Assistants
    accepts AMA PRA Category 1 Credit(s)TM from
    organizations accredited by the ACCME .

10
  • Rainu Kaushal, MD, MPH
  • Associate Professor of Pediatrics and Public
    Health,
  • Weill Medical College of Cornell University
  • Director of Pediatric Quality and Safety, KCCH at
    NYPH
  • New York, New York

11
The Role of Health Information Technology in
Medication Safety
  • April 25, 2007
  • 1200 100 p.m. EDT

12
Learning Objectives
  • Upon completion of this activity, you will be
    able to
  • Review the epidemiology of ambulatory medication
    safety in pediatrics.
  • Describe the role of health information
    technology in improving medication safety.
  • Utilize specific health information technology
    applications.

13
Historical Perspective
  • In 1925, 4 main types of adverse events
    identified for hospitalized patients
  • Burns due to hot water
  • Delirious patients jumping from hospital windows
  • Accidents connected with hospital elevators
  • Mistakes in the use of drugs

Aikens C. Study in the Ethics for Nurses.
Philadelphia Saunders 1925
14
Patient Safety and Medical Errors Become a
National Concern
November 29, 1999
15
(No Transcript)
16
IOM Report Preventing Medication Errors
  • One medication error per day per inpatient
  • Variation across institutions
  • At least 25 of injuries from medications are
    preventable
  • Annual preventable injuries from medications
  • 380,000-450,000 in hospitals for 3.5 billion
  • 800,000 in long-term care
  • 530,000 in Medicare ambulatory patients for 887
    million

17
Preventing Medication Errors Recommendations
  • Patients rights and enhancing consumer
    information
  • Utilizing HIT
  • Prescribing and transmission of all prescriptions
    electronically by 2010
  • Appropriate clinical decision support
  • Adopt other appropriate technology (eMAR, bar
    coding, smart iv pumps)
  • Monitor for medication errors
  • Standards for HIT
  • More research
  • Pediatrics a prime focus area

18
Overview
  • Why medication errors occur in children
  • Pediatric medication error epidemiology
  • Inpatient
  • Outpatient
  • Prevention strategies
  • HIT
  • Safety and quality
  • Financial

19
Why medication errors occur in children
  • Weight based dosing
  • Stock medicine dilution
  • Ten fold errors
  • Decreased communication abilities
  • Inability to self-administer medications
  • Increased vulnerability of young, critically ill
    children
  • Immature renal and hepatic systems

20
Definitions
Medication Errors
ADEs
Near Misses

21
Comparisons of Adult and Pediatric Inpatients
  • Pediatrics
    Adults
  • Orders reviewed 10,778
    10,070
  • Medication errors 616 (5.7) 530
    (5.3)
  • Near Misses 115 (1.1) 35 (0.35)
  • ADEs 26 (0.24) 25 (0.25)
  • Preventable ADEs 5 (0.05) 5
    (0.05)
  • p value
  • Study performed at Brigham and Womens Hospital
    in 1992 using similar methods

Kaushal et al, JAMA 2001
22
Error Stage for Medication Errors
23
Near Misses in the NICU per 100 orders



PJAMA 20012852114-20
24
Ambulatory Setting Medication Errors
  • 2952 medication errors
  • 1.6 errors per patient
  • 1.3 errors per prescription
  • 521 (12) rx inappropriate abbreviation
  • 1389 (64) rx partially illegible

25
Preliminary Results For Six Office Practices
26
Stages
Preventable ADEs
Near Misses
27
Why Do Errors Occur?
  • Physician writes an order
  • Nursing, pharmacist, and clerical staff
    mechanisms are in place to carry out orders
  • What occurs in reality?

28
We deliver medications in hospitals in a manner
that essentially hasnt changed in 60 years.
physician writes order
pharmacist checks order/allergies
nurse checks patient, drug, dose, route, time
secretary transcribes
pharmacist checks drug interactions
nurse administers drug
nurse double checks
pharmacy tech loads drawer
Is a double check necessary?
secretary faxes
pharmacy tech places drawer in delivery system
Is drug administered via pump
pharmacist receives fax
nurse obtains drug from delivery system
If order incorrect multiple other steps
pharmacist enter order
nurse checks drug against med sheets
29
We deliver medications in hospitals in a manner
that essentially hasnt changed in 60 years.
physician writes order
pharmacist checks order/allergies
nurse checks patient, drug, dose, route, time
secretary transcribes
pharmacist checks drug interactions
nurse administers drug
  • Consider Whats the error rate in each one of
    these steps - 5, 1, 0.1, 0.01

nurse double checks
pharm. tech loads drawer
Is a double check necessary?
secretary faxes
pharm. tech places drawer in meditrol
Is drug administered via pump
pharmacist receives fax
nurse obtains drug from meditrol
If order incorrect multiple other steps
pharmacist enter order
nurse checks drug against med sheets
30
The Role of Complexity inPreventing Errors
  • Probability of Performing Perfectly

31
No one makes an error on purpose.
  • Lucian Leape

32
Everyone makes dumb mistakes every day.
33
No one admits an error if you punish them for it.
34
Error Reduction Systems Approach
  • Culture of Safety
  • Non-punitive systems
  • Multidisciplinary error prevention
  • Involve parents and families
  • Executive walk rounds
  • Medication Safety Initiative
  • Strong, clear, visible attention to safety
  • Avoid fatigue
  • Minimize distractions
  • Independent double checks
  • 2nd checker will detect 90 of errors made by
    first checker
  • HIT

35
How will HIT help?
  • Improve communication
  • What has been done and by whom
  • Improve accessibility
  • Paper records unavailable 1/3 of the time
  • Physicians spend 20-30 of their time searching
    for and organizing information
  • Require key pieces of information
  • Improve information retrieval
  • Impossible to store all needed clinical
    information in a physicians head

36
How will HIT help? (cont)
  • Just in time decision support
  • Assist with calculations
  • Make the right thing the easiest to do
  • Perform checks in real-time
  • Assist with monitoring
  • Advance the quality agenda
  • Quality measurement
  • Low cost way to diffuse evidence-based best
    practices

37
Impact of HIT on Quality, Efficiency and Costs
  • 4 Benchmark institutions
  • Quality
  • Increased adherence to guidelines
  • Enhanced surveillance and monitoring
  • Medication errors
  • Efficiency
  • Decreased utilization of care
  • Financial
  • Chaudhry B et al, Annals 2006

38
Types of HIT
  • EHR, Electronic health record
  • CPOE, Computerized physician order entry
  • Robots
  • Smart IV systems
  • Bar coding
  • Telemedicine
  • Automated drug delivery systems

39
CPOE Low hanging fruit
  • Illegible handwriting
  • Incomplete information
  • Unacceptable Abbreviations
  • Lack of leading zeros
  • Inclusion of trailing zeros

40
Key Areas of Decision Support
  • Requiring complete orders
  • Default doses
  • Drug-allergy checking
  • DDI checking
  • Renal dosing
  • Geriatric dosing
  • Drug-lab checking
  • Dose ceilings

41
Handwriting example
42
Corollary order reminders reduce errors of
omission
  • Target - corollary order pairs (n87)
  • NSAID creatinine level
  • Aminoglycoside drug levels, creatinine
  • Warfarin routine protimes
  • Intervention -- display reminder at time of
    ordering

Overhage JAMIA 19974364-375
43
Effect of alerts on compliance
Overhage JAMIA 19974364-375
44
Proportion of doses exceeding recommended maximum
Teich Archives Int Med 20001602741
45
Dosing appropriateness in patients with renal
impairment
Both results P Chertow JAMA 20012862839-44
46
Effect of an antibiotic advisor
All results statistically significant Costs, LOS
also reduced Evans NEJM 1998338232-238
47
Effect of Changing Default Dosing Frequency for
Ceftriaxone
48
NYPH -- Pediatric dosing decision support
Computer suggests 300 mg every 8 hours for this
patient based on age and weight
  • Evaluation
  • 32 of suggestions accepted exactly
  • Good reasons for not following
  • Subjectively, physicians like it
  • (Killela B, et al Pediatrics, 2007)

49
Results of Two Studies on Medication Error
Prevention
  • CPOE reduced medication errors by 80
  • CPOE reduced serious medication errors by 55

Bates et al, JAMA 1998
50
Evidence of Reduction in Errors
  • CPOE Pittsburgh Childrens
  • Harmful ADEs pre-CPOE 0.05/1000 doses
  • Post-CPOE 0.03/1000 doses (p0.05).
  • CPOE prevents 1 ADE every 64 patient days

Upperman et al. J Pediatr Surg 20054057-59
51
Evidence of Reduction in Errors
  • Mullett
  • Stand alone anti-infective CDSS in PICU
  • 59 decrease in the rate of pharmacy
    interventions for wrong drug doses
  • Potts
  • CPOE and medication ordering errors in PICU
  • Medication errors reduced 96
  • Near misses reduced 41

Mullett CJ, et al. Pediatrics 200110875-81 Potts
AL, et al. Pediatrics 200411359-63
52
So whats the problem?
  • High federal and state policy interest
  • Leapfrog group identified as 1 of 3 patient
    safety leaps
  • Only 10-15 of hospitals across the country have
    active CPOE systems
  • Few primary care physicians have CPOE
  • High stakes
  • Enormous institutional investment
  • Well-publicized failures

53
Unintended Consequences
  • I have ordered the test that was right next to
    the one I thought I ordered, you know, right
    below it that little thingie had come down and I
    clicked and Im lookin at this one but I in fact
    clicked on the thing before. By that time I
    turned my head and Im hitting return and typing
    my signature and not seeing it.

Ash, JAMIA 2005
54
,,
  • High cost and lack of capital
  • The number one barrier is cost. I have been
    doing hospital software for 29 years, and this is
    the most expensive project Ive ever done.
  • Cost benefit mis-match
  • CPOE may save a lot of money for the health
    care system overall, but the money is not being
    collected by the hospital.
  • For ambulatory CPOE, assuming 11.6 capitation
    rate nationally
  • 11 of ROI accrues to providers
  • 89 to other stakeholders, primarily payers

55
Errors in AdministrationIV Infusions
  • Rule of 6s intended for rapid dose calculation
    and drug preparation
  • If
  • conc of drug (mL/100 ml) 6 x patient weight
    (kg)
  • Then
  • dose (µg/kg per min) rate (mL/hour)
  • Calculation intensive
  • Numerous possible concentrations
  • If use standard drug concentrations, then rely on
    dosing charts

56
Errors in AdministrationIV Infusions
  • IV syringe pumps
  • Traditional infusion pumps prone to ADEs
  • Errors due to keypad data entry mistakes
  • Free-flow phenomena

57
Smart Pumps
  • Library of medications with standard
    concentrations specific to patient population
  • Makes calculations
  • Safety net
  • Hard limits (range cannot be overridden)
  • Soft limits (can be overridden)
  • Pump alarms and halts infusion if medication dose
    is programmed outside preset limits

58
Smart Pump with Standard Concentrations and
Redesigned Labels

pLarsen et al. Pediatrics 2005
59
Safe Practices for Communicating Test Results
  • Critical ambulatory safety issue
  • 75 of physicians did not notify patients of
    normal results
  • 33 of physicians did not even notify of abnormal
    results (Boohaker et al, Archives 1996)
  • Approximately 1/3 of women with abnormal
    mammograms or pap smears do not receive
    appropriate follow-up care

60
Improving Result Management Systems
  • Can be integrated with Electronic Medical Records
  • A tool that allows focus on truly abnormal test
    results
  • A tool that warns physicians if patients have
    missed tests
  • Use of standardized features, such as ticklers
  • Paper systems can also be highly successful
  • Standardized procedures rather than every
    physician doing it his/her own way

61
Results Manager Application
62
Strategy Automate Carefully
  • EHR
  • CPOE
  • Smart IV systems
  • Robots
  • Automated drug delivery systems
  • Bar coding
  • Inexpensive technology
  • 63 reduction in serious dispensing errors at BWH

63
Conclusions
  • Make safety top priority
  • Move from a culture of blame to one of safety
  • Stop blaming people for making errors
  • To err is human
  • Improve the system
  • Utilize technology as it becomes available
  • Involve patients/parents to the fullest extent
  • Measure and iteratively refine
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