Outcomes%20on%20Implementation%20of%20Electronic%20Medication%20Administration%20Records%20and%20CPOE - PowerPoint PPT Presentation

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Title: Outcomes%20on%20Implementation%20of%20Electronic%20Medication%20Administration%20Records%20and%20CPOE

Outcomes on Implementation of Electronic
Medication Administration Records and CPOE
  • Alan Chan, MD
  • Internal Medicine-Pediatrics

  • Michael Huke, Pharm D.
  • Melissa Gabriel, Pharm.D., BCPS
  • Jeff Hackman, MD Emergency Dept.

  • I was working on the CDC Universal Data
    Collection project for hemophilia and other blood
    disorders for adult and pediatrics.
  • A couple months ago, the project was shelved due
    to funding cuts and delays.
  • Im not sure if I should blame the federal budget
  • Full statistical analysis is not completed.

  • Something big happened at the end of August 2010!
  • Cerner GO-Live/Q6 for the CPOE (or Computer
    Physician Order entry) !!!
  • This will be referred to as the start date.

The Institute of Medicine
  • In 1999 article, notes 44,000 to 98,000 deaths
    due to medical errors.
  • To what extent these are directly related are
  • Computer physician order entry is one of the
    benchmarks for patient safety.
  • Defined by Leapfrog Group along with ICU
    staffing, High risk treatments/procedures, and
    Safe Practices Score
  • Also part of HITECH Act of 2009.
  • http//www.leapfroggroup.org/for_consumers/hospita
    ls_asked_what accessed 4/1/2011

University HealthSystem Consortium (UHC)
  • Consists of 113 academic medical centers and
    affialiated hospitals 90 of nations
    non-profits academic medical centers
  • Patient Safety Net (PSN) is a real time,
    Web-based event reporting system.
  • At Truman Medical Center (TMC), events can be
    logged into the system by any health care
  • https//www.uhc.edu/11851.htm accessed 4/1/2011

  • We believe that the initiation of the CPOE and
    electronic medication administration record
    (eMAR) would decrease total errors.
  • What new errors might be introduced?
  • Few studies exist to track these changes.

  • Search on PubMed limited to past 5 years, English
    print journals, and Humans.
  • Terms included electronic medical records and
    patient safety for 228 results and Adverse drug
    events computer physician order with 51
  • Some immediate references and citations to these
    results were used, which could include older
  • http//www.ncbi.nlm.nih.gov accessed 4/1/2011

Methods (cont)
  • TMC all areas (inpatient, outpatient, ER, BH)
  • CPOE system Powerchart Cerner
  • A retrospective review of PSN results were used
    these are self reported.
  • Time frame of 1, 3, and 6 months pre and post
    implementation were used.
  • A random sampling of 1 and 3 month windows were
    done to ensure similar number of reports.

  • Looked at ALL medications errors (med errors)
  • Sub groups of wrong medication and incorrect
    medication list separately and also together.
  • Looked at Adverse Drug Reactions (ADR), but not
    medication errors.
  • In these Med errors, looked at the type of
    outcome, whether it created an Unsafe, No Harm,
    or Harmful Event.

Medication errors 9 types
  1. Dose omission
  2. Extra dose given
  3. Wrong medication
  4. Prescription/refill delay
  5. Medication list was incorrect
  6. Monitoring error (includes contraindications)
  7. Unauthorized drug
  8. Inadequate pain management
  9. Other

Harm Score or Category of Events
  • Unsafe conditions (A)
  • Event, but no Harm
  • B1 near miss from chance
  • B2 near miss because of recovery efforts
  • C reached patient (pt), but no harm
  • D reached pt, and required additional
    monitoring to prevent harm
  • Event, but Harm
  • E pt temporary harm, and required treatment
  • F pt temporary harm, and required more
  • G permanent harm
  • H harm and required intervention to sustain
    life like ICU transfer
  • Death (I) one case, but unique circumstance.
  • Undetermined (X) - no cases

Results 1 month window
PRE before start date POST after start
date ARR is the Absolute risk reduction RRR
is the relative risk reduction
Results 3 month window
Results 6 month window
  • A few single months were checked before and after
    start date, and the overall results number of
    reported events are similar
  • The overall number of reports have been
    increasing over the past few years, so difficult
    to access much before the start date.
  • Overall, all types of errors are lower.

Results Harm score
These are number of medication errors
More errors?
  • Why more Unsafe errors?
  • More wrong med errors (from 5 to 10)
  • New type of error delay in getting med
  • A contraindication was displayed and noted
  • Other types
  • Why More Harmful errors?
  • Actually less Omission errors
  • More wrong med errors (from 5 to 7)
  • Other types
  • The other types may be mislabeled.

  • User generated reports, although members of the
    PSN team here review reports as they are
    generated in real-time.
  • Some other reports may not have been correctly
  • New unintended consequences one study at a
    tertiary pediatric center actually noted
    increased mortality.
  • Might affect time sensitive therapies like
    critical care settings.
  • Han YY, Carcillo JA, Venkataraman ST, et al.
    Unexpected increased mortality after
    implementation of a commercially sold
    computerized physician order entry system

Next steps
  • Review 1 year data
  • Evaluate whether this represents a fair sample of
    the cases.
  • Review the other category to make sure properly
    labeled cases
  • Look at ADR and mortality, latter difficult to
    evaluate with this.

Notable thoughts.
  • It takes time for providers to adopt
  • Pharmacy centralizes many medications
  • Providers may spend more time away from bedside
  • Physician workload will increase, but uncertain
  • Is this trade off worth the better documentation
    and e-paper trail?
  • More order set would decrease click through
  • Delays in opening electronic charts during heavy
    work times
  • Self reported events and ADR may not correlate
    with true rate.

Other thoughts
  • One study at a pediatric hospital saw overall
    decrease in hospital wide mortality with CPOE and
    electronic nursing documentation.
  • Studies at ICU areas show decrease in risk of
    medication errors, but no significant reduction
    in ADR or mortality.
  • Many studies have not been fully powered to
    detect the small number of ADR or mortality
  • We can look at 1 year data from start date.

  • http//www.leapfroggroup.org/for_consumers/hospita
    ls_asked_what accessed 4/1/2011
  • Han YY, Carcillo JA, Venkataraman ST, et al.
    Unexpected increased mortality after
    implementation of a commercially sold
    computerized physician order entry system
    published correction appears in Pediatrics.
    2006117(2)594. Pediatrics. 2005116(6)1506151
  • Van Rosse F, Maat B, Carin MA, et al. The Effect
    of CPOE on Medication Prescription Errors and
    Clinical Outcome in Pediatric and Intensive Care
    A Systemic Review. Pediatrics. 2009 123(4)
  • Sittig DF, Ash JS, Zhang J, et al. Lessons From
    "Unexpected Increased Mortality After
    Implementation of a Commercially Sold
    Computerized Physician Order Entry System.
    Pediatrics. 2006 118 797-801.
  • Longhurst CA, Parast L, Sandbord CI, et al.
    Decrease in Hospital-wide Mortality Rate After
  • Implementation of a Commercially Sold
    Computerized Physician Order Entry System.
    Pediatrics. 2010 126 14-21.
  • Kaushal R, Shojania KG, Bates DW. Effects of
    Computerized Physician Order Entry and Clinical
    Decision Support Systems on Medication Safety.
    Arch Intern Med. 2003 163 1409-1416.
  • http//www.cpoe.org/ From Oregon Health and
    Sciences University. Accessed 4/1/2011

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