Review Paper Medication-related Clinical Decision Support in Computerized Provider Order Entry Systems: A Review
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paper_title: Some Unintended Consequences of Information Technology in Health Care: The Nature of Patient Care Information System-related Errors

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Medical error reduction is an international issue, as is the implementation of patient care information systems (PCISs) as a potential means to achieving it. As researchers conducting separate studies in the United States, The Netherlands, and Australia, using similar qualitative methods to investigate implementing PCISs, the authors have encountered many instances in which PCIS applications seem to foster errors rather than reduce their likelihood. The authors describe the kinds of silent errors they have witnessed and, from their different social science perspectives (information science, sociology, and cognitive science), they interpret the nature of these errors. The errors fall into two main categories: those in the process of entering and retrieving information, and those in the communication and coordination process that the PCIS is supposed to support. The authors believe that with a heightened awareness of these issues, informaticians can educate, design systems, implement, and conduct research in such a way that they might be able to avoid the unintended consequences of these subtle silent errors.
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paper_title: Improving Safety with Information Technology

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Information technology can improve patient safety by preventing errors and facilitating rapid response to adverse events. Computerized prescribing by physicians reduces the rate of medication-related errors. Systems that automatically page clinicians about serious laboratory abnormalities and remote monitoring of patients in intensive care units also appear promising.
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paper_title: Patient safety and computerized medication ordering at Brigham and Women's Hospital.

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Article-at-a-Glance Background Medications are important therapeutic tools in health care, yet creating safe medication processes is challenging for many reasons. Computerized physician order entry (CPOE), one important way that technology can be used to improve the medication process, has been in place at Brigham and Women's Hospital (BWH; Boston) since 1993. CPOE at BWH The CPOE application, designed and developed internally by the BWH information systems team, allows physicians and other clinicians to enter all patient orders into the computer. Physicians enter 85% of orders, with the remainder entered electronically by other clinicians. CPOE and safe medication use The CPOE application at BWH includes several features designed to improve medication safety—structural features (for example, required fields, use of pick lists), enhanced workflow features (order sets, standard scales for insulin and potassium), alerts and reminders (drug–drug and drug–allergy interaction checking), and adjunct features (the pharmacy system, access to online reference information). Results at BWH Studies of the impact of CPOE on physician decision making and patient safety at BWH include assessment of CPOE's impact on the serious medication error and the preventable adverse drug event rate, the impact of computer guidelines on the use of vancomycin, the impact of guidelines on the use of heparin in patients at bed rest, and the impact of dosing suggestions on excessive dosing. Conclusion CPOE and several forms of clinical decision support targeted at increasing patient safety have substantially decreased the frequency of serious medication errors and have had an even bigger impact on the overall medication error rate.
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paper_title: Adverse Drug Events in Ambulatory Care

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Background Adverse events related to drugs occur frequently among inpatients, and many of these events are preventable. However, few data are available on adverse drug events among outpatients. We conducted a study to determine the rates, types, severity, and preventability of such events among outpatients and to identify preventive strategies. Methods We performed a prospective cohort study, including a survey of patients and a chart review, at four adult primary care practices in Boston (two hospital-based and two community-based), involving a total of 1202 outpatients who received at least one prescription during a four-week period. Prescriptions were computerized at two of the practices and handwritten at the other two. Results Of the 661 patients who responded to the survey (response rate, 55 percent), 162 had adverse drug events (25 percent; 95 percent confidence interval, 20 to 29 percent), with a total of 181 events (27 per 100 patients). Twenty-four of the events (13 percent) were serious, 51 (28...
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paper_title: Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group.

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OBJECTIVES ::: To assess incidence and preventability of adverse drug events (ADEs) and potential ADEs. To analyze preventable events to develop prevention strategies. ::: ::: ::: DESIGN ::: Prospective cohort study. ::: ::: ::: PARTICIPANTS ::: All 4031 adult admissions to a stratified random sample of 11 medical and surgical units in two tertiary care hospitals over a 6-month period. Units included two medical and three surgical intensive care units and four medical and two surgical general care units. ::: ::: ::: MAIN OUTCOME MEASURES ::: Adverse drug events and potential ADEs. ::: ::: ::: METHODS ::: Incidents were detected by stimulated self-report by nurses and pharmacists and by daily review of all charts by nurse investigators. Incidents were subsequently classified by two independent reviewers as to whether they represented ADEs or potential ADEs and as to severity and preventability. ::: ::: ::: RESULTS ::: Over 6 months, 247 ADEs and 194 potential ADEs were identified. Extrapolated event rates were 6.5 ADEs and 5.5 potential ADEs per 100 nonobstetrical admissions, for mean numbers per hospital per year of approximately 1900 ADEs and 1600 potential ADEs. Of all ADEs, 1% were fatal (none preventable), 12% life-threatening, 30% serious, and 57% significant. Twenty-eight percent were judged preventable. Of the life-threatening and serious ADEs, 42% were preventable, compared with 18% of significant ADEs. Errors resulting in preventable ADEs occurred most often at the stages of ordering (56%) and administration (34%); transcription (6%) and dispensing errors (4%) were less common. Errors were much more likely to be intercepted if the error occurred earlier in the process: 48% at the ordering stage vs 0% at the administration stage. ::: ::: ::: CONCLUSION ::: Adverse drug events were common and often preventable; serious ADEs were more likely to be preventable. Most resulted from errors at the ordering stage, but many also occurred at the administration stage. Prevention strategies should target both stages of the drug delivery process.
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paper_title: Risk factors for adverse drug events among nursing home residents.

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Background: In a prospective study of nursing home residents, we found adverse drug events (ADEs) to be common, serious, and often preventable. To direct prevention efforts at high-risk residents, information is needed on resident-level risk factors. Methods: Case-control study nested within a prospective study of ADEs among residents in 18 nursing homes. For each ADE, we randomly selected a control from the same home. Data were abstracted from medical records on functional status, medical conditions, and medication use.
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paper_title: A research agenda for bridging the 'quality chasm.'.

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Realizing the vision of the IOM's landmark report, Crossing the Quality Chasm, will require new knowledge to support new policy and management. This paper lays out a research agenda that must be pursued if the health care system is to bridge the quality chasm. Based on a consensus process involving leading health care researchers and authorities, the paper highlights knowledge gaps and research directions in five areas identified by the Quality Chasm report as critical to its goals of building organizational supports for change; applying evidence to health care delivery; developing information technology; aligning payment policies with quality improvement; and preparing the workforce.
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paper_title: Characteristics and Consequences of Drug Allergy Alert Overrides in a Computerized Physician Order Entry System

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OBJECTIVE ::: The aim of this study was to determine characteristics of drug allergy alert overrides, assess how often they lead to preventable adverse drug events (ADEs), and suggest methods for improving the allergy-alerting system. ::: ::: ::: DESIGN ::: Chart review was performed on a stratified random subset of all allergy alerts occurring during a 3-month period (August through October 2002) at a large academic hospital. ::: ::: ::: MEASUREMENTS ::: Factors that were measured were drug/allergy combinations that triggered alerts, frequency of specific override reasons, characteristics of ADEs, and completeness of allergy documentation. ::: ::: ::: RESULTS ::: A total of 6,182 (80%) of 7,761 alerts were overridden in 1,150 patients. In this sample, only 10% of alerts were triggered by an exact match between the drug ordered and allergy listed. Physicians' most common reasons for overriding alerts were "Aware/Will monitor" (55%), "Patient does not have this allergy/tolerates" (33%), and "Patient taking already" (10%). In a stratified random subset of 320 patients (28% of 1,150) on chart review, 19 (6%) experienced ADEs attributed to the overridden drug; of these, 9 (47%) were serious. None of the ADEs was considered preventable, because the overrides were deemed clinically justifiable. The degree of completeness of patients' allergy lists was highly variable and generally low in both paper charts and the CPOE system. ::: ::: ::: CONCLUSION ::: Overrides of drug-allergy alerts were common and about 1 in 20 resulted in ADEs, but all of the overrides resulting in ADEs appeared clinically justifiable. The high rate of alert overrides was attributable to frequent nonexact match alerts and infrequent updating of allergy lists. Based on these findings, we have made specific recommendations for increasing the specificity of alerting and thereby improving the clinical utility of the drug allergy alerting system.
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paper_title: Effective drug-allergy checking: methodological and operational issues

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Adverse drug events cause a large number of injuries, and adverse events caused by medications administered in the face of known allergies represent an important preventable cause of patient harm. Computerized systems can effectively prevent reactions due to known allergies, but building an effective allergy prevention feature is challenging and presents many interesting informatics issues that have both methodological and operational implications. In this paper, we present the experiences from one large delivery system in delivering allergy-related decision support, discuss some of the different approaches that we have used, and then propose a future approach. We also discuss the methodological, behavioral, and operational issues that have arisen which have a major impact on success. Key factors in drug-allergy checking include storing patient allergy data in a single common repository, representing allergy data using suitable terminologies and creating groups of allergies for inferencing purposes, being judicious about which allergy warnings to display, conveying the reaction that the patient has experienced when exposed to the drug to inform the provider of the importance of the warning, and perhaps most important, implementing strategies to optimize the likelihood that allergy information will be entered.
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paper_title: Improving allergy alerting in a computerized physician order entry system.

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Abstract ::: Computerized physician order entry has been shown to reduce the frequency of serious medication errors. Decision support tools such as alerting functions for patient medication allergy are a key part of these applications. However, optimal performance requires iterative refinement. As systems become increasingly complex, mechanisms to monitor their performance become increasingly critical. We analyzed trend data obtained over a five-year period that showed decreasing compliance to allergy alert functions within computerized order entry. Many medication-allergy pairs were being consistently overridden. Renewal policies affecting reordering narcotics also contributed heavily to this trend. Each factor revealed a system-wide trend that could result in suggestions for policy or software change. Monitoring trends such as these is very important to maintain software correctness and ensure user trust in alerting systems, so users remain responsive to computerized alerts.
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paper_title: Creating an enterprise-wide allergy repository at Partners HealthCare System.

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A significant fraction of medication errors and preventable adverse drug events are related to drug-allergy interactions (DAIs). Computerized prescribing can help prevent DAIs, but an accurate record of the patient's allergies is required. At Partners HealthCare System in Boston, the patient's allergy list is distributed across several applications including computer physician order entry (CPOE), the outpatient medical record, pharmacy applications, and nurse charting applications. Currently, each application has access only to its own allergy data. This paper presents details of a project designed to integrate the various allergy repositories at Partners. We present data documenting that patients have allergy data stored in multiple repositories. We give detail about issues we are encountering such as which applications should participate in the repository, whether "NKA" or "NKDA" should be used to document known absence of allergies, and which personnel should be allowed to enter allergies. The issues described in this paper may well be faced by other initiatives intended to create comprehensive allergy repositories.
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paper_title: Using Commercial Knowledge Bases for Clinical Decision Support: Opportunities, Hurdles, and Recommendations

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The quality and safety of health care leaves much to be desired.1,2 Automated clinical decision support (CDS) tools embedded in clinical information systems (CISs) such as computer provider order entry (CPOE) and electronic health records (EHR) applications have the potential to improve care and should be part of any comprehensive approach to improve quality.3,4,5,6 Medication prescribing is a component of health care with well documented quality and safety problems that can be improved by CDS.7,8,9 ::: ::: Medication-related CDS requires that pharmaceutical knowledge be represented in a computable, explicit and unambiguous form. Creating an automated representation of medical knowledge often is the most time consuming step in the development of a CDS system and is known as the “knowledge acquisition bottleneck.”10 For a time, it was hoped that the move toward explicit guidelines in medicine would decrease the knowledge acquisition effort,11 but that has not happened.12 Experiments on data sharing from over a decade ago have not progressed.13 As a result, just a few organizations, primarily academic medical centers, are creating rules and benefiting from CDS,14 but most health care organizations do not have the expertise or resources to create such knowledge bases themselves. ::: ::: One potential solution to the problem of access to automated medication-related knowledge is the set of commercial vendors that supply medication-related knowledge bases for pharmacy and prescribing applications. These vendors' products contain such knowledge as drug-drug and drug-disease interactions, minimum and maximum dosing suggestions, drug-allergy cross-sensitivity groupings, and groupings of medications by therapeutic class. Developers of CISs (either vendor-based or “homegrown”), with appropriate licensing, can incorporate commercial knowledge bases into their products. The knowledge base vendor receives a licensing fee for each CIS implementation and can amortize the …
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paper_title: Effects of computerized physician order entry on prescribing practices.

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BACKGROUND ::: Computerized order entry systems have the potential to prevent errors, to improve quality of care, and to reduce costs by providing feedback and suggestions to the physician as each order is entered. This study assesses the impact of an inpatient computerized physician order entry system on prescribing practices. ::: ::: ::: METHODS ::: A time series analysis was performed at an urban academic medical center at which all adult inpatient orders are entered through a computerized system. When physicians enter drug orders, the computer displays drug use guidelines, offers relevant alternatives, and suggests appropriate doses and frequencies. ::: ::: ::: RESULT ::: For medication selection, use of a computerized guideline resulted in a change in use of the recommended drug (nizatidine) from 15.6% of all histamine(2)-blocker orders to 81.3% (P<.001). Implementation of dose selection menus resulted in a decrease in the SD of drug doses by 11% (P<.001). The proportion of doses that exceeded the recommended maximum decreased from 2.1% before order entry to 0.6% afterward (P<.001). Display of a recommended frequency for ondansetron hydrochloride administration resulted in an increase in the use of the approved frequency from 6% of all ondansetron orders to 75% (P<.001). The use of subcutaneous heparin sodium to prevent thrombosis in patients at bed rest increased from 24% to 47% when the computer suggested this option (P<.001). All these changes persisted at 1- and 2-year follow-up analyses. ::: ::: ::: CONCLUSION ::: Computerized physician order entry is a powerful and effective tool for improving physician prescribing practices.
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paper_title: The Epidemiology of Prescribing Errors The Potential Impact of Computerized Prescriber Order Entry

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BACKGROUND ::: Adverse drug events (ADEs) are the most common cause of injury to hospitalized patients and are often preventable. Medication errors resulting in preventable ADEs most commonly occur at the prescribing stage. ::: ::: ::: OBJECTIVES ::: To describe the epidemiology of medication prescribing errors averted by pharmacists and to assess the likelihood that these errors would be prevented by implementing computerized prescriber order entry (CPOE). ::: ::: ::: METHODS ::: At a 700-bed academic medical center in Chicago, Ill, clinical staff pharmacists saved all orders that contained a prescribing error for a week in early 2002. Pharmacist investigators subsequently classified drug class, error type, proximal cause, phase of hospitalization, and potential for patient harm and rated the likelihood that CPOE would have prevented the prescribing error. ::: ::: ::: RESULTS ::: A total of 1111 prescribing errors were identified (62.4 errors per 1000 medication orders), most occurring on admission (64%). Of these, 30.8% were rated clinically significant and were most frequently related to anti-infective medication orders, incorrect dose, and medication knowledge deficiency. Of all verified prescribing errors, 64.4% were rated as likely to be prevented with CPOE (including 43% of the potentially harmful errors), 13.2% unlikely to be prevented with CPOE, and 22.4% possibly prevented with CPOE depending on specific CPOE system characteristics. ::: ::: ::: CONCLUSIONS ::: Prescribing errors are common in the hospital setting. While CPOE systems could improve practitioner prescribing, design and implementation of a CPOE system should focus on errors with the greatest potential for patient harm. Pharmacist involvement, in addition to a CPOE system with advanced clinical decision support, is vital for achieving maximum medication safety.
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paper_title: Guided Prescription of Psychotropic Medications for Geriatric Inpatients

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Background Inappropriate use or excessive dosing of psychotropic medications in the elderly is common and can lead to a variety of adverse drug events including falls, oversedation, and cognitive impairment. Methods We developed a database of psychotropic medication dosing and selection guidelines for elderly inpatients. We displayed these recommendations to physicians through a computerized order entry system at a tertiary care academic hospital. The system was activated for 2 of 4 six-week study periods in an off-on-off-on pattern. Main outcome measures were agreement with the recommended daily dose for the initial drug order, incidence of dosing at least 10-fold greater than the recommended daily dose, prescription of nonrecommended drugs, inpatient falls, altered mental status as measured by a brief nursing assessment, and hospital length of stay. Results A total of 7456 initial orders for psychotropic medications were prescribed for 3718 hospitalized elderly patients with a mean ± SD age of 74.7 ± 6.7 years. The intervention increased the prescription of the recommended daily dose (29% vs 19%; P P P P = .001). No effect on hospital length of stay or days of altered mental status was found. Conclusion A geriatric decision support system for psychotropic medications increased the prescription of recommended doses, reduced the prescription of nonrecommended drugs, and was associated with fewer inpatient falls.
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paper_title: Factors related to errors in medication prescribing.

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Objective. —To quantify the type and frequency of identifiable factors associated with medication prescribing errors. Design and Setting. —Systematic evaluation of every third prescribing error detected and averted by pharmacists in a 631-bed tertiary care teaching hospital between July 1,1994, and June 30, 1995. Each error was concurrently evaluated for the potential to result in adverse patient consequences. Each error was retrospectively evaluated by a physician and 2 pharmacists and a factor likely related to the error was identified. Participants. —All physicians prescribing medications during the study period and all staff pharmacists involved in the routine review of medication orders. Main Outcome Measures. —Frequency of association of factors likely related to medication errors in general and specific to medication classes and prescribing services (needed for medical, pediatric, obstetric-gynecologic, surgical, or emergency department patients); and potential consequences of errors for negative patient outcomes. Results. —A total of 2103 errors thought to have potential clinical importance were detected during the 1-year study period. The overall rate of errors was 3.99 errors per 1000 medication orders, and the error rate varied among medication classes and prescribing services. A total of 696 errors met study criteria (ie, errors with the potential for adverse patient effects) and were evaluated for a likely related factor. The most common specific factors associated with errors were decline in renal or hepatic function requiring alteration of drug therapy (97 errors, 13.9%), patient history of allergy to the same medication class (84 errors, 12.1%), using the wrong drug name, dosage form, or abbreviation (total of 79 errors, 11.4%, for both brand name and generic name orders), incorrect dosage calculations (77 errors, 11.1%), and atypical or unusual and critical dosage frequency considerations (75 errors, 10.8%). The most common groups of factors associated with errors were those related to knowledge and the application of knowledge regarding drug therapy (209 errors, 30%); knowledge and use of knowledge regarding patient factors that affect drug therapy (203 errors, 29.2%); use of calculations, decimal points, or unit and rate expression factors (122 errors, 17.5%); and nomenclature factors (incorrect drug name, dosage form, or abbreviation) (93 errors, 13.4%). Conclusions. —Several easily identified factors are associated with a large proportion of medication prescribing errors. By improving the focus of organizational, technological, and risk management educational and training efforts using the factors commonly associated with prescribing errors, risk to patients from adverse drug events should be reduced.
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paper_title: Outpatient prescribing errors and the impact of computerized prescribing

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BACKGROUND ::: Medication errors are common among inpatients and many are preventable with computerized prescribing. Relatively little is known about outpatient prescribing errors or the impact of computerized prescribing in this setting. ::: ::: ::: OBJECTIVE ::: To assess the rates, types, and severity of outpatient prescribing errors and understand the potential impact of computerized prescribing. ::: ::: ::: DESIGN ::: Prospective cohort study in 4 adult primary care practices in Boston using prescription review, patient survey, and chart review to identify medication errors, potential adverse drug events (ADEs) and preventable ADEs. ::: ::: ::: PARTICIPANTS ::: Outpatients over age 18 who received a prescription from 24 participating physicians. ::: ::: ::: RESULTS ::: We screened 1879 prescriptions from 1202 patients, and completed 661 surveys (response rate 55%). Of the prescriptions, 143 (7.6%; 95% confidence interval (CI) 6.4% to 8.8%) contained a prescribing error. Three errors led to preventable ADEs and 62 (43%; 3% of all prescriptions) had potential for patient injury (potential ADEs); 1 was potentially life-threatening (2%) and 15 were serious (24%). Errors in frequency (n=77, 54%) and dose (n=26, 18%) were common. The rates of medication errors and potential ADEs were not significantly different at basic computerized prescribing sites (4.3% vs 11.0%, P=.31; 2.6% vs 4.0%, P=.16) compared to handwritten sites. Advanced checks (including dose and frequency checking) could have prevented 95% of potential ADEs. ::: ::: ::: CONCLUSIONS ::: Prescribing errors occurred in 7.6% of outpatient prescriptions and many could have harmed patients. Basic computerized prescribing systems may not be adequate to reduce errors. More advanced systems with dose and frequency checking are likely needed to prevent potentially harmful errors.
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paper_title: Patient safety and computerized medication ordering at Brigham and Women's Hospital.

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Article-at-a-Glance Background Medications are important therapeutic tools in health care, yet creating safe medication processes is challenging for many reasons. Computerized physician order entry (CPOE), one important way that technology can be used to improve the medication process, has been in place at Brigham and Women's Hospital (BWH; Boston) since 1993. CPOE at BWH The CPOE application, designed and developed internally by the BWH information systems team, allows physicians and other clinicians to enter all patient orders into the computer. Physicians enter 85% of orders, with the remainder entered electronically by other clinicians. CPOE and safe medication use The CPOE application at BWH includes several features designed to improve medication safety—structural features (for example, required fields, use of pick lists), enhanced workflow features (order sets, standard scales for insulin and potassium), alerts and reminders (drug–drug and drug–allergy interaction checking), and adjunct features (the pharmacy system, access to online reference information). Results at BWH Studies of the impact of CPOE on physician decision making and patient safety at BWH include assessment of CPOE's impact on the serious medication error and the preventable adverse drug event rate, the impact of computer guidelines on the use of vancomycin, the impact of guidelines on the use of heparin in patients at bed rest, and the impact of dosing suggestions on excessive dosing. Conclusion CPOE and several forms of clinical decision support targeted at increasing patient safety have substantially decreased the frequency of serious medication errors and have had an even bigger impact on the overall medication error rate.
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paper_title: Large Errors in the Dosing of Medications for Children

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To the Editor: Dosing errors are among the most common types of medication errors.1–3 Errors by a factor of 10 (the administration of a dose 10 times or 1/10 as high as appropriate) are of particul...
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paper_title: Impact of a computerized alert during physician order entry on medication dosing in patients with renal impairment.

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Computerized assistance to clinicians during physician order entry can provide protection against medical errors. However, computer systems that provide too much assistance may adversely affect training of medical students and residents. Trainees may rely on the computer to automatically perform complex calculations and create appropriate orders and are thereby deprived of an important educational exercise. An alternative strategy is to provide a critique at the completion of an order, requiring the trainee to enter the entire order but displaying an alert if an error is made. While this approach preserves the educational components of order-writing, the potential for errors exists if the computerized critique does not induce clinicians to correct the order. The goal of this study was to determine (a) the frequency with which errors are made by trainees in an environment in which renal dosing adjustment calculation for antimicrobials are done by the system after the user has entered an order, and (b) the frequency with which prompts to clinicians regarding these errors leads to correction of those orders.
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paper_title: Medication error prevention by clinical pharmacists in two children's hospitals.

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The purpose of this study was to record prospectively the frequency of and potential harm caused by errant medication orders at two large pediatric hospitals. The objective of the study was to assess the impact of pharmacist intervention in preventing potential harm. The study was conducted during a 6-month period. A total of 281 and 198 errors were detected at the institutions. The overall error rates for the two hospitals were 1.35 and 1.77 per 100-patient days, and 4.9 and 4.5 per 1,000 medication orders, respectively. Pediatric patients aged 2 years and less and pediatric intensive care unit patients received the greatest proportion of errant orders. Neonatal patients received the lowest rate of errant orders. The most common type of error was incorrect dosage, and the most prevalent type of error was overdosage. Antibiotics was the class of drugs for which errant orders were most common. Orders for theophylline, analgesics, and fluid and electrolytes, including hyperalimentation, were also frequently in error. In general, the error rate was greatest among physicians with the least training, but no physician group was error free. Involving pharmacists in reviewing drug orders significantly reduced the potential harm resulting from errant medication orders.
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paper_title: Effects of computerized physician order entry on prescribing practices.

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BACKGROUND ::: Computerized order entry systems have the potential to prevent errors, to improve quality of care, and to reduce costs by providing feedback and suggestions to the physician as each order is entered. This study assesses the impact of an inpatient computerized physician order entry system on prescribing practices. ::: ::: ::: METHODS ::: A time series analysis was performed at an urban academic medical center at which all adult inpatient orders are entered through a computerized system. When physicians enter drug orders, the computer displays drug use guidelines, offers relevant alternatives, and suggests appropriate doses and frequencies. ::: ::: ::: RESULT ::: For medication selection, use of a computerized guideline resulted in a change in use of the recommended drug (nizatidine) from 15.6% of all histamine(2)-blocker orders to 81.3% (P<.001). Implementation of dose selection menus resulted in a decrease in the SD of drug doses by 11% (P<.001). The proportion of doses that exceeded the recommended maximum decreased from 2.1% before order entry to 0.6% afterward (P<.001). Display of a recommended frequency for ondansetron hydrochloride administration resulted in an increase in the use of the approved frequency from 6% of all ondansetron orders to 75% (P<.001). The use of subcutaneous heparin sodium to prevent thrombosis in patients at bed rest increased from 24% to 47% when the computer suggested this option (P<.001). All these changes persisted at 1- and 2-year follow-up analyses. ::: ::: ::: CONCLUSION ::: Computerized physician order entry is a powerful and effective tool for improving physician prescribing practices.
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paper_title: Guided Prescription of Psychotropic Medications for Geriatric Inpatients

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Background Inappropriate use or excessive dosing of psychotropic medications in the elderly is common and can lead to a variety of adverse drug events including falls, oversedation, and cognitive impairment. Methods We developed a database of psychotropic medication dosing and selection guidelines for elderly inpatients. We displayed these recommendations to physicians through a computerized order entry system at a tertiary care academic hospital. The system was activated for 2 of 4 six-week study periods in an off-on-off-on pattern. Main outcome measures were agreement with the recommended daily dose for the initial drug order, incidence of dosing at least 10-fold greater than the recommended daily dose, prescription of nonrecommended drugs, inpatient falls, altered mental status as measured by a brief nursing assessment, and hospital length of stay. Results A total of 7456 initial orders for psychotropic medications were prescribed for 3718 hospitalized elderly patients with a mean ± SD age of 74.7 ± 6.7 years. The intervention increased the prescription of the recommended daily dose (29% vs 19%; P P P P = .001). No effect on hospital length of stay or days of altered mental status was found. Conclusion A geriatric decision support system for psychotropic medications increased the prescription of recommended doses, reduced the prescription of nonrecommended drugs, and was associated with fewer inpatient falls.
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paper_title: Conversion from intravenous to oral medications: assessment of a computerized intervention for hospitalized patients.

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BACKGROUND ::: Many hospitalized patients continue to receive intravenous medications longer than necessary. Earlier conversion from the intravenous to the oral route could increase patient safety and comfort, reduce costs, and facilitate earlier discharge from the hospital without compromising clinical care. We examined the effect of a computer-based intervention to prompt physicians to switch appropriate patients from intravenous to oral medications. ::: ::: ::: METHODS ::: This study was performed at Brigham and Women's Hospital, an academic tertiary care hospital at which all medications are ordered online. We targeted 5 medications with equal oral and intravenous bioavailability: fluconazole, levofloxacin, metronidazole, ranitidine, and amiodarone. We used the hospital's computerized order entry system to prompt physicians to convert appropriate intravenous medications to the oral route. We measured the total use of the targeted medications via each route in the 4 months before and after the implementation of the intervention. We also measured the rate at which physicians responded to the intervention when prompted. ::: ::: ::: RESULTS ::: The average intravenous defined daily dose declined by 11.1% (P =.002) from the preintervention to the postintervention period, while the average oral defined daily dose increased by 3.7% (P =.002). Length of stay, case-mix index, and total drug use at the hospital increased during the study period. The average total monthly use of the intravenous preparation of all of the targeted medications declined in the 4 months after the intervention began, compared with the 4 months before. In 35.6% of 1045 orders for which a prompt was generated, the physician either made a conversion from the intravenous to the oral version or canceled the order altogether. ::: ::: ::: CONCLUSIONS ::: Computer-generated reminders can produce a substantial reduction in excessive use of targeted intravenous medications. As online prescribing becomes more common, this approach can be used to reduce excess use of intravenous medications, with potential benefits in patient comfort, safety, and cost.
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paper_title: How to Design Computerized Alerts to Ensure Safe Prescribing Practices

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Article-at-a-Glance Background Medication errors and preventable adverse drug events are common, and about half of medication errors occur during medication ordering. This study was designed to develop and evaluate medication safety alerts and processes for educating prescribers about the alerts. Methods At Kaiser Permanente Northwest, a group-model health maintenance organization where prescribers have used computerized order entry since 1996, qualitative interviews were conducted with 20 primary care prescribers. Results Prescribers considered alerts helpful for providing prescribing and preventive health information. More than half the interviewees stated that it would be unwise to let clinicians control or avoid safety alerts. Common frustrations were (1) being delayed by the alert, (2) having difficulty interpreting the alert, and (3) receiving the same alert repeatedly. Most prescribers preferred small-group educational sessions tied to existing meetings and having local physicians conduct education sessions. Discussion The findings were used to design a strategy for introducing and promoting the interventions, modifying the alert text and tools, and focusing the education on how clinicians could use the alerts effectively.
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paper_title: Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors

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ContextHospital computerized physician order entry (CPOE) systems are widely ::: regarded as the technical solution to medication ordering errors, the largest ::: identified source of preventable hospital medical error. Published studies ::: report that CPOE reduces medication errors up to 81%. Few researchers, however, ::: have focused on the existence or types of medication errors facilitated by ::: CPOE.ObjectiveTo identify and quantify the role of CPOE in facilitating prescription ::: error risks.Design, Setting, and ParticipantsWe performed a qualitative and quantitative study of house staff interaction ::: with a CPOE system at a tertiary-care teaching hospital (2002-2004). We surveyed ::: house staff (N = 261; 88% of CPOE users); conducted 5 focus groups ::: and 32 intensive one-on-one interviews with house staff, information technology ::: leaders, pharmacy leaders, attending physicians, and nurses; shadowed house ::: staff and nurses; and observed them using CPOE. Participants included house ::: staff, nurses, and hospital leaders.Main Outcome MeasureExamples of medication errors caused or exacerbated by the CPOE system.ResultsWe found that a widely used CPOE system facilitated 22 types of medication ::: error risks. Examples include fragmented CPOE displays that prevent a coherent ::: view of patients’ medications, pharmacy inventory displays mistaken ::: for dosage guidelines, ignored antibiotic renewal notices placed on paper ::: charts rather than in the CPOE system, separation of functions that facilitate ::: double dosing and incompatible orders, and inflexible ordering formats generating ::: wrong orders. Three quarters of the house staff reported observing each of ::: these error risks, indicating that they occur weekly or more often. Use of ::: multiple qualitative and survey methods identified and quantified error risks ::: not previously considered, offering many opportunities for error reduction.ConclusionsIn this study, we found that a leading CPOE system often facilitated ::: medication error risks, with many reported to occur frequently. As CPOE systems ::: are implemented, clinicians and hospitals must attend to errors that these ::: systems cause in addition to errors that they prevent.
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paper_title: Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients

paper_content:

A 1999 Institute of Medicine report received national attention by highlighting system vulnerabilities within health care and indicating that medication errors are a leading cause of morbidity and mortality. One area of concern was the increased number of errors occurring in the prescribing phase of the medication-use process due to prescribers’ lack of essential drug knowledge and patient information at the time of ordering. Pharmacists’ participation in medical rounds has demonstrated a reduction in medication errors in the ordering stage. However, at most hospitals, pharmacists are not directly involved in obtaining medication histories, despite the findings of one study showing that over 70% of drug-related problems were recognized only through a patient interview and another study reporting a 51% reduction in medication errors when pharmacists were involved in obtaining medication histories. Medication errors and patient harm can result from inaccurate or incomplete histories that are subsequently used to generate medication KRISTINE M. GLEASON, B.S.PHARM., is Research Pharmacist Coordinator; JENNIFER M. GROSZEK, R.N., B.S.N., M.J., and CAROL SULLIVAN, R.N., M.B.A., are Research Nurse Coordinators, Patient Safety Team; DENISE ROONEY, R.N., B.S.N., O.C.N., is Manager, Patient Safety Team; and CYNTHIA BARNARD, M.B.A., M.S.J.S., C.P.H.Q., is Director, Quality Strategies and Patient Safety Team, Division of Quality and Operations, Northwestern Memorial Hospital (NMH), Chicago, IL. GARY A. NOSKIN, M.D., is Associate Professor of Medicine, Department of Medicine, Division of Infectious Diseases, Feinberg School of Medicine, Northwestern University, Chicago, and Medical Director, Healthcare Epidemiology and Quality, NMH. Address correspondence to Ms. Gleason at the Division of Quality and Operations, Northwestern Memorial Hospital, 676 North St. Clair Street, Suite 700, Chicago, IL 60611 (kmgleaso@nmh.org). The Patient Safety Team and Failure Mode and Effects Analysis team members at Northwestern Memorial Hospital are acknowledged for their active participation and support. Karen Nordstrom, B.S.Pharm., Michael Fotis, B.S.Pharm., and Desi Kotis, Pharm.D., provided invaluable assistance and insight into this project. The dedicated clinical staff pharmacists are acknowledged for enhancing patient safety by obtaining medication and allergy histories, reconciling discrepancies in medication histories and orders, and collecting data. Supported in part by an Excellence in Academic Medicine Grant from the State of Illinois Department of Public Aid and U.S. Public Health Service grant UR8/515081. Presented at the ASHP Midyear Clinical Meeting, Atlanta, GA, December 11, 2002; the 5th Annual National Patient Safety Foundation Patient Safety Congress, Washington, DC, March 12–14, 2003; and the Institute for Healthcare Improvement 15th Annual National Forum on Quality Improvement in Health Care, New Orleans, LA, December 4, 2003.
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paper_title: Improving Acceptance of Computerized Prescribing Alerts in Ambulatory Care

paper_content:

Computerized drug prescribing alerts can improve patient safety, but are often overridden because of poor specificity and alert overload. Our objective was to improve clinician acceptance of drug alerts by designing a selective set of drug alerts for the ambulatory care setting and minimizing workflow disruptions by designating only critical to high-severity alerts to be interruptive to clinician workflow. The alerts were presented to clinicians using computerized prescribing within an electronic medical record in 31 Boston-area practices. There were 18,115 drug alerts generated during our six-month study period. Of these, 12,933 (71%) were noninterruptive and 5,182 (29%) interruptive. Of the 5,182 interruptive alerts, 67% were accepted. Reasons for overrides varied for each drug alert category and provided potentially useful information for future alert improvement. These data suggest that it is possible to design computerized prescribing decision support with high rates of alert recommendation acceptance by clinicians.
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paper_title: Medication-prescribing errors in a teaching hospital. A 9-year experience.

paper_content:

BACKGROUND ::: Improved understanding of medication prescribing errors should be useful in the design of error prevention strategies. ::: ::: ::: OBJECTIVE ::: To report analysis of a 9-year experience with a systematic program of detecting, recording, and evaluating medication-prescribing errors in a teaching hospital. ::: ::: ::: METHODS ::: All medication-prescribing errors with potential for adverse patient outcome detected and averted by staff pharmacists from January 1, 1987, through December 31, 1995, were systematically recorded and analyzed. Errors were evaluated by type of error, medication class involved, prescribing service, potential severity, time of day, and month. Data were analyzed to determine changes in medication-prescribing error frequency and characteristics occurring during the 9-year study period. ::: ::: ::: RESULTS ::: A total of 11,186 confirmed medication-prescribing errors with potential for adverse patient consequences were detected and averted during the study period. The annual number of errors detected increased from 522 in the index year 1987 to 2115 in 1995. The rate of errors occurring per order written, per admission, and per patient-day, all increased significantly during the study duration (P < .001). Increased error rates were correlated with the number of admissions (P < .001). Antimicrobials, cardiovascular agents, gastrointestinal agents, and narcotics were the most common medication classes involved in errors. The most common type of errors were dosing errors, prescribing medications to which the patient was allergic, and prescribing inappropriate dosage forms. ::: ::: ::: CONCLUSIONS ::: The results of this study suggest there may exist a progressively increasing risk of adverse drug events for hospitalized patients. The increased rate of errors is possibly associated with increases in the intensity of medical care and use of drug therapy. Limited changes in the characteristics of prescribing errors occurred, as similar type errors were found to be repeated with increasing frequency. New errors were encountered as new drug therapies were introduced. Health care practitioners and health care systems must incorporate adequate error reduction, prevention, and detection mechanisms into the routine provision of care.
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paper_title: Medication Prescribing Errors in a Teaching Hospital

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A study of prescribing errors committed by physicians that occurred in a tertiarycare teaching hospital is reported. From a total of 289 411 medication orders written during the 1-year study period, 905 prescribing errors were detected and averted, of which 522 (57.7%) were rated as having potential for adverse consequences. The overall detected error rate was 3.13 errors for each 1000 orders written and a rate of 1.81 significant errors per 1000 orders. The error rate (4.01 per 1000 orders) was greatest between 12 PM and 3:59 PM. First-year postgraduate residents were found to have a higher error rate (4.25 per 1000 orders) than other prescriber classes, and obstetrics/gynecology services (3.54 per 1000 orders) and surgery/anesthesia services (3.42 per 1000 orders) had greater error rates than other services. The study results demonstrate the significant risk to patients from medication prescribing errors. Educational, operational, and risk-management activities should include efforts directed at reducing the risk to patients from prescribing errors. (JAMA. 1990;263:2329-2334)
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paper_title: Impact of Computerized Prescriber Order Entry on Medication Errors at an Acute Tertiary Care Hospital

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The authors analyzed medication errors documented in a hospital's database of clinical interventions as a continuous quality improvement activity. They compared the number of errors reported prior to and after computerized prescriber order entry (CPOE) was implemented in the hospital. Results indicated that in the first 12 months of CPOE, overall medication errors were reduced by more than 40%, incomplete orders declined by more than 70%, and incorrect orders decreased by at least 45%. Illegible orders were virtually eliminated but the level of medication errors categorized by drug therapy problems remained significantly unchanged. The study underscores the positive impact of CPOE on medication safety and reemphasizes the need for proactive clinical interventions by pharmacists.
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paper_title: Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group.

paper_content:

OBJECTIVES ::: To assess incidence and preventability of adverse drug events (ADEs) and potential ADEs. To analyze preventable events to develop prevention strategies. ::: ::: ::: DESIGN ::: Prospective cohort study. ::: ::: ::: PARTICIPANTS ::: All 4031 adult admissions to a stratified random sample of 11 medical and surgical units in two tertiary care hospitals over a 6-month period. Units included two medical and three surgical intensive care units and four medical and two surgical general care units. ::: ::: ::: MAIN OUTCOME MEASURES ::: Adverse drug events and potential ADEs. ::: ::: ::: METHODS ::: Incidents were detected by stimulated self-report by nurses and pharmacists and by daily review of all charts by nurse investigators. Incidents were subsequently classified by two independent reviewers as to whether they represented ADEs or potential ADEs and as to severity and preventability. ::: ::: ::: RESULTS ::: Over 6 months, 247 ADEs and 194 potential ADEs were identified. Extrapolated event rates were 6.5 ADEs and 5.5 potential ADEs per 100 nonobstetrical admissions, for mean numbers per hospital per year of approximately 1900 ADEs and 1600 potential ADEs. Of all ADEs, 1% were fatal (none preventable), 12% life-threatening, 30% serious, and 57% significant. Twenty-eight percent were judged preventable. Of the life-threatening and serious ADEs, 42% were preventable, compared with 18% of significant ADEs. Errors resulting in preventable ADEs occurred most often at the stages of ordering (56%) and administration (34%); transcription (6%) and dispensing errors (4%) were less common. Errors were much more likely to be intercepted if the error occurred earlier in the process: 48% at the ordering stage vs 0% at the administration stage. ::: ::: ::: CONCLUSION ::: Adverse drug events were common and often preventable; serious ADEs were more likely to be preventable. Most resulted from errors at the ordering stage, but many also occurred at the administration stage. Prevention strategies should target both stages of the drug delivery process.
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paper_title: Accuracy of Data in Computer-based Patient Records

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Data in computer-based patient records (CPRs) have many uses beyond their primary role in patient care, including research and health-system management. Although the accuracy of CPR data directly affects these applications, there has been only sporadic interest in, and no previous review of, data accuracy in CPRs. This paper reviews the published studies of data accuracy in CPRs. These studies report highly variable levels of accuracy. This variability stems from differences in study design, in types of data studied, and in the CPRs themselves. These differences confound interpretation of this literature. We conclude that our knowledge of data accuracy in CPRs is not commensurate with its importance and further studies are needed. We propose methodological guidelines for studying accuracy that address shortcomings of the current literature. As CPR data are used increasingly for research, methods used in research databases to continuously monitor and improve accuracy should be applied to CPRs.
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paper_title: Improving Acceptance of Computerized Prescribing Alerts in Ambulatory Care

paper_content:

Computerized drug prescribing alerts can improve patient safety, but are often overridden because of poor specificity and alert overload. Our objective was to improve clinician acceptance of drug alerts by designing a selective set of drug alerts for the ambulatory care setting and minimizing workflow disruptions by designating only critical to high-severity alerts to be interruptive to clinician workflow. The alerts were presented to clinicians using computerized prescribing within an electronic medical record in 31 Boston-area practices. There were 18,115 drug alerts generated during our six-month study period. Of these, 12,933 (71%) were noninterruptive and 5,182 (29%) interruptive. Of the 5,182 interruptive alerts, 67% were accepted. Reasons for overrides varied for each drug alert category and provided potentially useful information for future alert improvement. These data suggest that it is possible to design computerized prescribing decision support with high rates of alert recommendation acceptance by clinicians.
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paper_title: Clinical Relevance of Automated Drug Alerts From the Perspective of Medical Providers

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The authors used a real-time survey instrument and subsequent focus group among primary care clinicians at a large healthcare system to assess usefulness of automated drug alerts. Of 108 alerts encountered, 0.9% (n = 1) represented critical alerts, and 16% (n = 17) were significant drug interaction alerts. Sixty-one percent (n = 66) involved duplication of a medication or medication class. The rest (n = 24) involved topical medications, inhalers, or vaccines. Of the 84 potentially relevant alerts, providers classified 11% (9/84), or about 1 in 9, as useful. Drug interaction alerts were more often deemed useful than drug duplication alerts (44.4% versus 1.5%, P< .001). Focus group participants generally echoed these results when ranking the relevance of 15 selected alerts, although there was wide variance in ratings for individual alerts. Hence, a “smarter” system that utilizes a set of mandatory alerts while allowing providers to tailor use of other automated warnings may improve clinical relevance of dru...
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paper_title: Physicians' decisions to override computerized drug alerts in primary care.

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BACKGROUND ::: Although computerized physician order entry reduces medication errors among inpatients, little is known about the use of this system in primary care. ::: ::: ::: METHODS ::: We calculated the override rate among 3481 consecutive alerts generated at 5 adult primary care practices that use a common computerized physician order entry system for prescription writing. For detailed review, we selected a random sample of 67 alerts in which physicians did not prescribe an alerted medication and 122 alerts that resulted in a written prescription. We identified factors associated with the physicians' decisions to override a medication alert, and determined whether an adverse drug event (ADE) occurred. ::: ::: ::: RESULTS ::: Physicians overrode 91.2% of drug allergy and 89.4% of high-severity drug interaction alerts. In the multivariable analysis using the medical chart review sample (n = 189), physicians were less likely to prescribe an alerted medication if the prescriber was a house officer (odds ratio [OR], 0.26; 95% confidence interval [CI], 0.08-0.84) and if the patient had many drug allergies (OR, 0.70; 95% CI, 0.53-0.93). They were more likely to override alerts for renewals compared with new prescriptions (OR, 17.74; 95% CI, 5.60-56.18). We found no ADEs in cases where physicians observed the alert and 3 ADEs among patients with alert overrides, a nonsignificant difference (P =.55). Physician reviewers judged that 36.5% of the alerts were inappropriate. ::: ::: ::: CONCLUSIONS ::: Few physicians changed their prescription in response to a drug allergy or interaction alert, and there were few ADEs, suggesting that the threshold for alerting was set too low. Computerized physician order entry systems should suppress alerts for renewals of medication combinations that patients currently tolerate.
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paper_title: Characteristics and override rates of order checks in a practitioner order entry system.

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Order checks are important error prevention tools when used in conjunction with practitioner order entry systems. We studied characteristics of order checks generated in a sample of consecutively entered orders during a 4 week period in an electronic medical record at VA Puget Sound. We found that in the 42,641 orders where an order check could potentially be generated, 11% generated at least one order check and many generated more than one order check. The rates at which the ordering practitioner overrode 'Critical drug interaction' and 'Allergy-drug interaction' alerts in this sample were 88% and 69% respectively. This was in part due to the presence of alerts for interactions between systemic and topical medications and for alerts generated during medication renewals. Refinement in order check logic could lead to lower override rates and increase practitioner acceptance and effectiveness of order checks.
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paper_title: Using Commercial Knowledge Bases for Clinical Decision Support: Opportunities, Hurdles, and Recommendations

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The quality and safety of health care leaves much to be desired.1,2 Automated clinical decision support (CDS) tools embedded in clinical information systems (CISs) such as computer provider order entry (CPOE) and electronic health records (EHR) applications have the potential to improve care and should be part of any comprehensive approach to improve quality.3,4,5,6 Medication prescribing is a component of health care with well documented quality and safety problems that can be improved by CDS.7,8,9 ::: ::: Medication-related CDS requires that pharmaceutical knowledge be represented in a computable, explicit and unambiguous form. Creating an automated representation of medical knowledge often is the most time consuming step in the development of a CDS system and is known as the “knowledge acquisition bottleneck.”10 For a time, it was hoped that the move toward explicit guidelines in medicine would decrease the knowledge acquisition effort,11 but that has not happened.12 Experiments on data sharing from over a decade ago have not progressed.13 As a result, just a few organizations, primarily academic medical centers, are creating rules and benefiting from CDS,14 but most health care organizations do not have the expertise or resources to create such knowledge bases themselves. ::: ::: One potential solution to the problem of access to automated medication-related knowledge is the set of commercial vendors that supply medication-related knowledge bases for pharmacy and prescribing applications. These vendors' products contain such knowledge as drug-drug and drug-disease interactions, minimum and maximum dosing suggestions, drug-allergy cross-sensitivity groupings, and groupings of medications by therapeutic class. Developers of CISs (either vendor-based or “homegrown”), with appropriate licensing, can incorporate commercial knowledge bases into their products. The knowledge base vendor receives a licensing fee for each CIS implementation and can amortize the …
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paper_title: Customizing a commercial rule base for detecting drug-drug interactions.

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We developed and implemented an adverse drug event system (PharmADE) that detects potentially dangerous drug combinations using a commercial rule base. While commercial rule bases can be useful for rapid deployment of a safety net to screen for drug-drug interactions, they sometimes do not provide the desired rule sensitivity. We implemented methods for enhancing commercial drug-drug interaction rules while preserving the original rule base architecture for easy and low cost maintenance.
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paper_title: Effects of computerized physician order entry on prescribing practices.

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BACKGROUND ::: Computerized order entry systems have the potential to prevent errors, to improve quality of care, and to reduce costs by providing feedback and suggestions to the physician as each order is entered. This study assesses the impact of an inpatient computerized physician order entry system on prescribing practices. ::: ::: ::: METHODS ::: A time series analysis was performed at an urban academic medical center at which all adult inpatient orders are entered through a computerized system. When physicians enter drug orders, the computer displays drug use guidelines, offers relevant alternatives, and suggests appropriate doses and frequencies. ::: ::: ::: RESULT ::: For medication selection, use of a computerized guideline resulted in a change in use of the recommended drug (nizatidine) from 15.6% of all histamine(2)-blocker orders to 81.3% (P<.001). Implementation of dose selection menus resulted in a decrease in the SD of drug doses by 11% (P<.001). The proportion of doses that exceeded the recommended maximum decreased from 2.1% before order entry to 0.6% afterward (P<.001). Display of a recommended frequency for ondansetron hydrochloride administration resulted in an increase in the use of the approved frequency from 6% of all ondansetron orders to 75% (P<.001). The use of subcutaneous heparin sodium to prevent thrombosis in patients at bed rest increased from 24% to 47% when the computer suggested this option (P<.001). All these changes persisted at 1- and 2-year follow-up analyses. ::: ::: ::: CONCLUSION ::: Computerized physician order entry is a powerful and effective tool for improving physician prescribing practices.
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paper_title: A computer-assisted management program for antibiotics and other antiinfective agents.

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BACKGROUND AND METHODS ::: Optimal decisions about the use of antibiotics and other antiinfective agents in critically ill patients require access to a large amount of complex information. We have developed a computerized decision-support program linked to computer-based patient records that can assist physicians in the use of antiinfective agents and improve the quality of care. This program presents epidemiologic information, along with detailed recommendations and warnings. The program recommends antiinfective regimens and courses of therapy for particular patients and provides immediate feedback. We prospectively studied the use of the computerized antiinfectives-management program for one year in a 12-bed intensive care unit. ::: ::: ::: RESULTS ::: During the intervention period, all 545 patients admitted were cared for with the aid of the antiinfectives-management program. Measures of processes and outcomes were compared with those for the 1136 patients admitted to the same unit during the two years before the intervention period. The use of the program led to significant reductions in orders for drugs to which the patients had reported allergies (35, vs. 146 during the preintervention period; P<0.01), excess drug dosages (87 vs. 405, P<0.01), and antibiotic-susceptibility mismatches (12 vs. 206, P<0.01). There were also marked reductions in the mean number of days of excessive drug dosage (2.7 vs. 5.9, P<0.002) and in adverse events caused by antiinfective agents (4 vs. 28, P<0.02). In analyses of patients who received antiinfective agents, those treated during the intervention period who always received the regimens recommended by the computer program (n=203) had significant reductions, as compared with those who did not always receive the recommended regimens (n= 195) and those in the preintervention cohort (n = 766), in the cost of antiinfective agents (adjusted mean, $102 vs. $427 and $340, respectively; P<0.001), in total hospital costs (adjusted mean, $26,315 vs. $44,865 and $35,283; P<0.001), and in the length of the hospital stay days (adjusted mean, 10.0 vs. 16.7 and 12.9; P<0.001). CONCLUSIONS; A computerized antiinfectives-management program can improve the quality of patient care and reduce costs.
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paper_title: Guided Prescription of Psychotropic Medications for Geriatric Inpatients

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Background Inappropriate use or excessive dosing of psychotropic medications in the elderly is common and can lead to a variety of adverse drug events including falls, oversedation, and cognitive impairment. Methods We developed a database of psychotropic medication dosing and selection guidelines for elderly inpatients. We displayed these recommendations to physicians through a computerized order entry system at a tertiary care academic hospital. The system was activated for 2 of 4 six-week study periods in an off-on-off-on pattern. Main outcome measures were agreement with the recommended daily dose for the initial drug order, incidence of dosing at least 10-fold greater than the recommended daily dose, prescription of nonrecommended drugs, inpatient falls, altered mental status as measured by a brief nursing assessment, and hospital length of stay. Results A total of 7456 initial orders for psychotropic medications were prescribed for 3718 hospitalized elderly patients with a mean ± SD age of 74.7 ± 6.7 years. The intervention increased the prescription of the recommended daily dose (29% vs 19%; P P P P = .001). No effect on hospital length of stay or days of altered mental status was found. Conclusion A geriatric decision support system for psychotropic medications increased the prescription of recommended doses, reduced the prescription of nonrecommended drugs, and was associated with fewer inpatient falls.
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paper_title: Guided Medication Dosing for Inpatients With Renal Insufficiency

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ContextUsual drug-prescribing practices may not consider the effects of renal ::: insufficiency on the disposition of certain drugs. Decision aids may help ::: optimize prescribing behavior and reduce medical error.ObjectiveTo determine if a system application for adjusting drug dose and frequency ::: in patients with renal insufficiency, when merged with a computerized order ::: entry system, improves drug prescribing and patient outcomes.Design, Setting, and PatientsFour consecutive 2-month intervals consisting of control (usual computerized ::: order entry) alternating with intervention (computerized order entry plus ::: decision support system), conducted in September 1997–April 1998 with ::: outcomes assessed among a consecutive sample of 17 828 adults admitted ::: to an urban tertiary care teaching hospital.InterventionReal-time computerized decision support system for prescribing drugs ::: in patients with renal insufficiency. During intervention periods, the adjusted ::: dose list, default dose amount, and default frequency were displayed to the ::: order-entry user and a notation was provided that adjustments had been made ::: based on renal insufficiency. During control periods, these recommended adjustments ::: were not revealed to the order-entry user, and the unadjusted parameters were ::: displayed.Main Outcome MeasuresRates of appropriate prescription by dose and frequency, length of stay, ::: hospital and pharmacy costs, and changes in renal function, compared among ::: patients with renal insufficiency who were hospitalized during the intervention ::: vs control periods.ResultsA total of 7490 patients were found to have some degree of renal insufficiency. ::: In this group, 97 151 orders were written on renally cleared or nephrotoxic ::: medications, of which 14 440 (15%) had at least 1 dosing parameter modified ::: by the computer based on renal function. The fraction of prescriptions deemed ::: appropriate during the intervention vs control periods by dose was 67% vs ::: 54% (P<.001) and by frequency was 59% vs 35% (P<.001). Mean (SD) length of stay was 4.3 (4.5) days ::: vs 4.5 (4.8) days in the intervention vs control periods, respectively (P = .009). There were no significant differences in estimated ::: hospital and pharmacy costs or in the proportion of patients who experienced ::: a decline in renal function during hospitalization.ConclusionsGuided medication dosing for inpatients with renal insufficiency appears ::: to result in improved dose and frequency choices. This intervention demonstrates ::: a way in which computer-based decision support systems can improve care.
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paper_title: The Impact of Computerized Physician Order Entry on Medication Error Prevention

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BACKGROUND ::: Medication errors are common, and while most such errors have little potential for harm they cause substantial extra work in hospitals. A small proportion do have the potential to cause injury, and some cause preventable adverse drug events. ::: ::: ::: OBJECTIVE ::: To evaluate the impact of computerized physician order entry (POE) with decision support in reducing the number of medication errors. ::: ::: ::: DESIGN ::: Prospective time series analysis, with four periods. ::: ::: ::: SETTING AND PARTICIPANTS ::: All patients admitted to three medical units were studied for seven to ten-week periods in four different years. The baseline period was before implementation of POE, and the remaining three were after. Sophistication of POE increased with each successive period. ::: ::: ::: INTERVENTION ::: Physician order entry with decision support features such as drug allergy and drug-drug interaction warnings. ::: ::: ::: MAIN OUTCOME MEASURE ::: Medication errors, excluding missed dose errors. ::: ::: ::: RESULTS ::: During the study, the non-missed-dose medication error rate fell 81 percent, from 142 per 1,000 patient-days in the baseline period to 26.6 per 1,000 patient-days in the final period (P < 0.0001). Non-intercepted serious medication errors (those with the potential to cause injury) fell 86 percent from baseline to period 3, the final period (P = 0.0003). Large differences were seen for all main types of medication errors: dose errors, frequency errors, route errors, substitution errors, and allergies. For example, in the baseline period there were ten allergy errors, but only two in the following three periods combined (P < 0.0001). ::: ::: ::: CONCLUSIONS ::: Computerized POE substantially decreased the rate of non-missed-dose medication errors. A major reduction in errors was achieved with the initial version of the system, and further reductions were found with addition of decision support features.
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paper_title: Implementing renal impairment and geriatric decision support in ambulatory e-prescribing.

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An advanced decision support system for prescribing to patients with renal impairment and geriatric patients was successfully implemented in an ambulatory electronic medical record (EMR) system.
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paper_title: Drug-age alerting for outpatient geriatric prescriptions: a joint study using interoperable drug standards.

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For more than a decade, the Beers criteria have identified specific medications that should generally be avoided in the geriatric population. Studies that have shown high prevalence rates of these potentially inappropriate medications have used disparate methodologies to identify these medications and hence are difficult to replicate and generalize. In an effort to improve prescribing behavior, we are building a drug-age alerting system utilizing standard drug coding systems for use in our Electronic Health Record (EHR) systems.
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paper_title: Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group.

paper_content:

OBJECTIVES ::: To assess incidence and preventability of adverse drug events (ADEs) and potential ADEs. To analyze preventable events to develop prevention strategies. ::: ::: ::: DESIGN ::: Prospective cohort study. ::: ::: ::: PARTICIPANTS ::: All 4031 adult admissions to a stratified random sample of 11 medical and surgical units in two tertiary care hospitals over a 6-month period. Units included two medical and three surgical intensive care units and four medical and two surgical general care units. ::: ::: ::: MAIN OUTCOME MEASURES ::: Adverse drug events and potential ADEs. ::: ::: ::: METHODS ::: Incidents were detected by stimulated self-report by nurses and pharmacists and by daily review of all charts by nurse investigators. Incidents were subsequently classified by two independent reviewers as to whether they represented ADEs or potential ADEs and as to severity and preventability. ::: ::: ::: RESULTS ::: Over 6 months, 247 ADEs and 194 potential ADEs were identified. Extrapolated event rates were 6.5 ADEs and 5.5 potential ADEs per 100 nonobstetrical admissions, for mean numbers per hospital per year of approximately 1900 ADEs and 1600 potential ADEs. Of all ADEs, 1% were fatal (none preventable), 12% life-threatening, 30% serious, and 57% significant. Twenty-eight percent were judged preventable. Of the life-threatening and serious ADEs, 42% were preventable, compared with 18% of significant ADEs. Errors resulting in preventable ADEs occurred most often at the stages of ordering (56%) and administration (34%); transcription (6%) and dispensing errors (4%) were less common. Errors were much more likely to be intercepted if the error occurred earlier in the process: 48% at the ordering stage vs 0% at the administration stage. ::: ::: ::: CONCLUSION ::: Adverse drug events were common and often preventable; serious ADEs were more likely to be preventable. Most resulted from errors at the ordering stage, but many also occurred at the administration stage. Prevention strategies should target both stages of the drug delivery process.
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paper_title: High Rates of Adverse Drug Events in a Highly Computerized Hospital

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Background Numerous studies have shown that specific computerized interventions may reduce medication errors, but few have examined adverse drug events (ADEs) across all stages of the computerized medication process. We describe the frequency and type of inpatient ADEs that occurred following the adoption of multiple computerized medication ordering and administration systems, including computerized physician order entry (CPOE). Methods Using explicit standardized criteria, pharmacists classified inpatient ADEs from prospective daily reviews of electronic medical records from a random sample of all admissions during a 20-week period at a Veterans Administration hospital. We analyzed ADEs that necessitated a changed treatment plan. Results Among 937 hospital admissions, 483 clinically significant inpatient ADEs were identified, accounting for 52 ADEs per 100 admissions and an incidence density of 70 ADEs per 1000 patient-days. One quarter of the hospitalizations had at least 1 ADE. Of all ADEs, 9% resulted in serious harm, 22% in additional monitoring and interventions, 32% in interventions alone, and 11% in monitoring alone; 27% should have resulted in additional interventions or monitoring. Medication errors contributed to 27% of these ADEs. Errors associated with ADEs occurred in the following stages: 61% ordering, 25% monitoring, 13% administration, 1% dispensing, and 0% transcription. The medical record reflected recognition of 76% of the ADEs. Conclusions High rates of ADEs may continue to occur after implementation of CPOE and related computerized medication systems that lack decision support for drug selection, dosing, and monitoring.
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paper_title: Monitoring in chronic disease: a rational approach

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> “Know which abnormality you are going to follow during treatment. Pick something you can measure.” ::: > ::: > Meador C. A Little Book of Doctors' Rules.Lyons: IARC Press, 1999 ::: The ritual of routine visits for most chronic diseases usually includes monitoring to check on the progress or regress of the disease and the development of complications. Such checks require that we choose what to monitor, when to monitor, and how to adjust treatment. Poor choices in each can lead to poor control, poor use of time, and dangerous adjustments to treatment. For example, an audit of serum digoxin monitoring in a UK teaching hospital more than 20 years ago showed that the logic behind more than 80% of the tests requested could not be established, the timing of tests reflected poor understanding of the clinical pharmacokinetics, and about one result in four was followed by an inappropriate clinical decision.1 Improvements are possible. For example, a computerised reminder of inappropriate testing reduced the volume of testing for the concentration of antiepileptic drugs by 20%2; a decision support system for anticoagulation with warfarin led to an improvement from 45% to 63% of patients being within target range3; and quality control charts for peak flow measurements for people with asthma could detect exacerbations four days earlier than conventional methods.4 Given the extent of monitoring, even modest improvements are likely to improve benefits for patients and may reduce costs. ::: ::: Monitoring is periodic measurement that guides the management of a chronic or recurrent condition. It can be done by clinicians, patients, or both. In Australia, monitoring comprises between a third and half of all tests ordered in general practice and outpatients (Pirozzo, personal communication, 2002). Despite the considerable staff time and resources involved, monitoring is a surprisingly understudied area. We review the current literature (based on a Medline search using the terms “monitor*“, …
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paper_title: A Randomized Trial of "Corollary Orders" to Prevent Errors of Omission

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Objective: Errors of omission are a common cause of systems failures. Physicians often fail to order tests or treatments needed to monitor/ameliorate the effects of other tests or treatments. The authors hypothesized that automated, guideline-based reminders to physicians, provided as they wrote orders, could reduce these omissions. ::: ::: Design: The study was performed on the inpatient general medicine ward of a public teaching hospital. Faculty and housestaff from the Indiana University School of Medicine, who used computer workstations to write orders, were randomized to intervention and control groups. As intervention physicians wrote orders for 1 of 87 selected tests or treatments, the computer suggested corollary orders needed to detect or ameliorate adverse reactions to the trigger orders. The physicians could accept or reject these suggestions. ::: ::: Results: During the 6-month trial, reminders about corollary orders were presented to 48 intervention physicians and withheld from 41 control physicians. Intervention physicians ordered the suggested corollary orders in 46.3% of instances when they received a reminder, compared with 21.9% compliance by control physicians (p < 0.0001). Physicians discriminated in their acceptance of suggested orders, readily accepting some while rejecting others. There were one third fewer interventions initiated by pharmacists with physicians in the intervention than control groups. ::: ::: Conclusion: This study demonstrates that physician workstations, linked to a comprehensive electronic medical record, can be an efficient means for decreasing errors of omissions and improving adherence to practice guidelines.
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paper_title: Comparison of an anticoagulation clinic with usual medical care: anticoagulation control, patient outcomes, and health care costs.

paper_content:

BACKGROUND ::: The outcomes of an inception cohort of patients seen at an anticoagulation clinic (AC) were published previously. The temporary closure of this clinic allowed the evaluation of 2 more inception cohorts: usual medical care and an AC. ::: ::: ::: OBJECTIVE ::: To compare newly anticoagulated patients who were treated with usual medical care with those treated at an AC for patient characteristics, anticoagulation control, bleeding and thromboembolic events, and differences in costs for hospitalizations and emergency department visits. ::: ::: ::: RESULTS ::: Rates are expressed as percentage per patient-year. Patients treated at an AC who received lower-range anticoagulation had fewer international normalized ratios greater than 5.0 (7.0% vs 14.7%), spent more time in range (40.0% vs 37.0%), and spent less time at an international normalized ratio greater than 5 (3.5% vs 9.8%). Patients treated at an AC who received higher-range anticoagulation had more international normalized ratios within range (50.4% vs 35.0%), had fewer international normalized ratios less than 2.0 (13.0% vs 23.8%), and spent more time within range (64.0% vs 51.0%). The AC group had lower rates (expressed as percentage per patient-year) of significant bleeding (8.1% vs 35.0%), major to fatal bleeding (1.6% vs 3.9%), and thromboembolic events (3.3% vs 11.8%); the AC group also demonstrated a trend toward a lower mortality rate (0% vs 2.9%; P= .09). Significantly lower annual rates of warfarin sodium-related hospitalizations (5% vs 19%) and emergency department visits (6% vs 22%) reduced annual health care costs by $132086 per 100 patients. Additionally, a lower rate of warfarin-unrelated emergency department visits (46.8% vs 168.0%) produced an additional annual savings in health care costs of $29 72 per 100 patients. ::: ::: ::: CONCLUSIONS ::: A clinical pharmacist-run AC improved anticoagulation control, reduced bleeding and thromboembolic event rates, and saved $162058 per 100 patients annually in reduced hospitalizations and emergency department visits.
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paper_title: Appropriateness of antiepileptic drug level monitoring

paper_content:

Objectives. —To develop explicit, reliable appropriateness criteria for antiepileptic drug level monitoring and to assess the appropriateness of monitoring in one tertiary care institution. Design. —Appropriateness criteria derived from the literature and through expert opinion were used to evaluate a stratified random sample of antiepileptic drug level determinations obtained from chart review. Setting. —Tertiary care center performing more than 10 000 antiepileptic drug level determinations per year. Patients. —A total of 330 inpatients in whom antiepileptic drug levels were measured a total of 855 times. Methods. —Drug levels were assessed at least 200 times for each of four antiepileptic drugs (phenytoin, carbamazepine, phenobarbital, and valproic acid). Main Outcome Measures. —The proportion of antiepileptic drug levels with an appropriate indication and, of those, the proportion sampled appropriately. Results. —Overall, 27% (95% confidence interval, 24% to 30%) of levels had an appropriate indication. Interrater agreement for appropriateness was substantial (κ=0.61). There was no significant difference in the appropriateness rate among the four drugs (range, 25% to 29%). Of the 624 antiepileptic drug level determinations considered inappropriate (73%), only four (0.6%) were more than 20% higher than the upper limit of normal, and none of the four patients had clinical signs of drug toxicity. A median of six levels (range, one through 69) was determined per patient, and the median interval between level determinations was 24 hours. Of the 27% of level determinations with an appropriate indication, 51% were sampled correctly, resulting in an overall appropriateness rate of 14%. Conclusions. —Only 27% of antiepileptic drug level determinations had an appropriate indication, and half of these were not sampled correctly. Routine daily monitoring without pharmacological justification accounted for most of the inappropriate drug level determinations. Efforts to decrease inappropriate monitoring may result in substantial cost reductions without missing important clinical results. ( JAMA . 1995;274:1622-1626)
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paper_title: Adherence to black box warnings for prescription medications in outpatients.

paper_content:

BACKGROUND ::: Few data are available regarding the prevalence of potentially dangerous drug-drug, drug-laboratory, and drug-disease interactions among outpatients. Our objectives were to determine how frequently clinicians prescribe drugs in violation of black box warnings for these issues and to determine how frequently such prescribing results in harm. ::: ::: ::: METHODS ::: In an observational study of 51 outpatient practices using an electronic health record, we measured the frequency with which patients received prescriptions in violation of black box warnings for drug-drug, drug-laboratory, and/or drug-disease interactions. We performed medical record reviews in a sample of patients to detect adverse drug events. Multivariate analysis was conducted to assess the relationship of prescribing in violation of black box warnings to patient and clinician characteristics, adjusting for potential confounders and clustering. ::: ::: ::: RESULTS ::: Of 324 548 outpatients who received a medication in 2002, 2354 (0.7%) received a prescription in violation of a black box warning. After adjustment, receipt of medication in violation of a black box warning was more likely when patients were 75 years or older or female. The number of medications taken, the number of medical problems, and the site of care were also associated with violations. Less than 1% of patients who received a drug in violation of a black box warning had an adverse drug event as a result. ::: ::: ::: CONCLUSIONS ::: About 7 in 1000 outpatients received a prescription violating a black box warning. Few incidents resulted in detectable harm.
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paper_title: A Computer-Based Intervention for Improving the Appropriateness of Antiepileptic Drug Level Monitoring

paper_content:

We designed and implemented 2 automated, computerized screens for use at the time of antiepileptic drug (AED) test order entry to improve appropriateness by reminding physicians when a potentially redundant test was ordered and providing common indications for monitoring and pharmacokinetics of the specific AED. All computerized orders for inpatient serum AED levels during two 3-month periods were included in the study. During the 3-month period after implementation of the automated intervention, 13% of all AED tests ordered were canceled following computerized reminders. For orders appearing redundant, the cancellation rate was 27%. For nonredundant orders, 4% were canceled when
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paper_title: Incidence and possible causes of prescribing potentially hazardous/contraindicated drug combinations in general practice.

paper_content:

BACKGROUND ::: Preventing the use of medications where there is the potential for serious drug-drug interactions or drug-disease interactions (contraindications) is essential to ensure patient safety. Previous studies have looked at the incidence of prescribing contraindicated drug combinations, but little is known about the underlying reasons for the co-prescribing events. The objectives of this study were to estimate the incidence of prescribing contraindicated drug combinations in general practice and to explore the clinical context, possible causes and potential systems failures leading to their occurrence. ::: ::: ::: METHODS ::: A list of contraindicated drug combinations was compiled according to established references. A search of computerised patient medication records was performed, followed by detailed chart review and assessment. The patient records from four general practices in an area of England were searched for a period of 1 year (1 June 1999-31 May 2000) to identify contraindicated drug combinations. All patients registered with the four participating practices during the study period were included (estimated n = 37 940). Medical records of the cases identified by the computer search were reviewed in detail and relevant information was extracted. Each case was then independently assessed by a pharmacist and a physician who judged whether the co-prescribing was justified and whether it was associated with an adverse drug event. Proximal causes and potential systems failures were suggested for each co-prescribing event. ::: ::: ::: MAIN OUTCOME MEASURES AND RESULTS ::: Fourteen patients with potential drug-drug interactions and 50 patients with potential drug-disease interactions were identified. Overall, these represent an incidence of 1.9 per 1000 patient-years (95% CI 1.5, 2.3) or 4.3 per 1000 patients being concurrently prescribed > or =2 drugs per year (95% CI 3.2, 5.4). 62 cases involving 63 co-prescribing events were reviewed. Two-thirds of these events involved medications that were initiated by hospital doctors. Awareness of the potential drug-drug or drug-disease interactions was documented in one-third of the events at the time of initial co-prescribing. Within the study period, the co-prescribing was judged to be not justified in 44 events (70%). Potential drug-drug interactions possibly resulted in two adverse drug events. The majority of contraindicated co-prescribing related to drug-disease interactions involved the use of propranolol or timolol eye drops for patients receiving bronchodilators and the use of amiodarone for patients receiving levothyroxine sodium. ::: ::: ::: CONCLUSION ::: The prescribing of contraindicated drug combinations was relatively rare in this study. Multiple possible causes and systems failures were identified and could be used to develop strategies for the prevention of prescribing errors involving contraindicated drug combinations in primary care.
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paper_title: Effects of Computerized Clinical Decision Support Systems on Practitioner Performance and Patient Outcomes: A Systematic Review

paper_content:

ContextDevelopers of health care software have attributed improvements in patient ::: care to these applications. As with any health care intervention, such claims ::: require confirmation in clinical trials.ObjectivesTo review controlled trials assessing the effects of computerized clinical ::: decision support systems (CDSSs) and to identify study characteristics predicting ::: benefit.Data SourcesWe updated our earlier reviews by searching the MEDLINE, EMBASE, Cochrane ::: Library, Inspec, and ISI databases and consulting reference lists through ::: September 2004. Authors of 64 primary studies confirmed data or provided additional ::: information.Study SelectionWe included randomized and nonrandomized controlled trials that evaluated ::: the effect of a CDSS compared with care provided without a CDSS on practitioner ::: performance or patient outcomes.Data ExtractionTeams of 2 reviewers independently abstracted data on methods, setting, ::: CDSS and patient characteristics, and outcomes.Data SynthesisOne hundred studies met our inclusion criteria. The number and methodologic ::: quality of studies improved over time. The CDSS improved practitioner performance ::: in 62 (64%) of the 97 studies assessing this outcome, including 4 (40%) of ::: 10 diagnostic systems, 16 (76%) of 21 reminder systems, 23 (62%) of 37 disease ::: management systems, and 19 (66%) of 29 drug-dosing or prescribing systems. ::: Fifty-two trials assessed 1 or more patient outcomes, of which 7 trials (13%) ::: reported improvements. Improved practitioner performance was associated with ::: CDSSs that automatically prompted users compared with requiring users to activate ::: the system (success in 73% of trials vs 47%; P = .02) ::: and studies in which the authors also developed the CDSS software compared ::: with studies in which the authors were not the developers (74% success vs ::: 28%; respectively, P = .001).ConclusionsMany CDSSs improve practitioner performance. To date, the effects on ::: patient outcomes remain understudied and, when studied, inconsistent.
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paper_title: Evaluating the Appropriateness of Digoxin Level Monitoring

paper_content:

BACKGROUND ::: Digoxin level determinations can be useful clinically in patients receiving digoxin therapy but are sometimes misused. ::: ::: ::: METHODS ::: Explicit appropriateness criteria were adapted from previously published criteria and revised using local expert opinion. They were then used to evaluate the appropriateness of random samples of inpatient and outpatient serum digoxin levels. Overall agreement between reviewers regarding appropriateness was good (K = 0.65). Patients in the study included 162 inpatients in whom 224 digoxin levels were measured and 117 outpatients in whom 130 digoxin levels were measured during a 6-month period. The main outcome measure was the proportion of digoxin levels with an appropriate indication. ::: ::: ::: RESULTS ::: Among inpatient levels, only 16% (95% confidence intervals [CI], 11%-20%) were appropriate. Of the 189 digoxin levels considered inappropriate, only 26 (14%) had a result of 2.3 nmol/L or more (> or =1.8 ng/ mL). None of these levels resulted in an important change in therapy, and no patient had a toxic reaction to the therapy. Among inappropriate levels, daily routine monitoring accounted for 78%. Of the 130 outpatient levels, 52% (95% CI, 44%-61%) were appropriate. Of 62 inappropriate levels, only 4 (6%) had a result of 2.3 nmol/L or more (> or =1.8 ng/mL). One result led to a change in therapy, but none of the patients were believed to experience a toxic reaction. Among the inappropriate levels, 87% of patients underwent early routine monitoring before a steady state was achieved. ::: ::: ::: CONCLUSIONS ::: A high proportion of digoxin levels were inappropriate, particularly among inpatients. In both groups, the primary reason tests were judged inappropriate was early routine monitoring. Few inappropriate tests resulted in important data. Interventions to improve the use of digoxin levels could potentially save substantial resources without missing important clinical results.
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paper_title: Improving Acceptance of Computerized Prescribing Alerts in Ambulatory Care

paper_content:

Computerized drug prescribing alerts can improve patient safety, but are often overridden because of poor specificity and alert overload. Our objective was to improve clinician acceptance of drug alerts by designing a selective set of drug alerts for the ambulatory care setting and minimizing workflow disruptions by designating only critical to high-severity alerts to be interruptive to clinician workflow. The alerts were presented to clinicians using computerized prescribing within an electronic medical record in 31 Boston-area practices. There were 18,115 drug alerts generated during our six-month study period. Of these, 12,933 (71%) were noninterruptive and 5,182 (29%) interruptive. Of the 5,182 interruptive alerts, 67% were accepted. Reasons for overrides varied for each drug alert category and provided potentially useful information for future alert improvement. These data suggest that it is possible to design computerized prescribing decision support with high rates of alert recommendation acceptance by clinicians.
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paper_title: Empirical Derivation of an Electronic Clinically Useful Problem Statement System

paper_content:

Problem lists are tools to improve patient management. In the medical record, they connect diagnoses to therapy, prognosis, and psychosocial issues. Computer-based problem lists enhance paper-based approaches by enabling cost-containment and quality assurance applications, but they require clinically expressive controlled vocabularies. Because existing controlled vocabularies do not represent problem statements at a clinically useful level, we derived a new canonical problem statement vocabulary through semi-automated analysis and distillation of providerentered problem lists collected over 6 years from 74 696 patients. We combined automated and manual methods to condense 891 770 problem statements entered by 1961 care providers at Grady Memorial Hospital in Atlanta, Georgia, to 15 534 Canonical Clinical Problem Statement System (CCPSS) terms. The nature and frequency of problem statements were characterized, interrelations among them were enumerated, and a database capturing the epidemiology of problems was created. The authors identified 23 503 problem relations (co-occurrences, sign‐ symptom complexes, and differential diagnoses) and 22 690 modifier words that further categorized “canonical” problems. To assess completeness, CCPSS content was compared with that of the 1997 Unified Medical Language System Metathesaurus (containing terms from 44 clinical vocabularies). Unified Medical Language System terms expressed 25% of individual CCPSS terms exactly (71% of problems by frequency), 27% partially, and 48% poorly or not at all. Clinicians judged that CCPSS terms completely captured their clinical intent for 84% of 686 randomly selected free-text problem statements. The CCPSS represents clinical concepts at a level exceeding that of previous approaches. A similar national approach could create a standardized, useful, shared resource for clinical practice.
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paper_title: Automated coded ambulatory problem lists: evaluation of a vocabulary and a data entry tool

paper_content:

Abstract Background: Problem lists are fundamental to electronic medical records (EMRs). However, obtaining an appropriate problem list dictionary is difficult, and getting users to code their problems at the time of data entry can be challenging. Objective: To develop a problem list dictionary and search algorithm for an EMR system and evaluate its use. Methods: We developed a problem list dictionary and lookup tool and implemented it in several EMR systems. A sample of 10,000 problem entries was reviewed from each system to assess overall coding rates. We also performed a manual review of a subset of entries to determine the appropriateness of coded entries, and to assess the reasons other entries were left uncoded. Results: The overall coding rate varied significantly between different EMR implementations (63–79%). Coded entries were virtually always appropriate (99%). The most frequent reasons for uncoded entries were due to user interface failures (44–45%), insufficient dictionary coverage (20–32%), and non-problem entries (10–12%). Conclusion: The problem list dictionary and search algorithm has achieved a good coding rate, but the rate is dependent on the specific user interface implementation. Problem coding is essential for providing clinical decision support, and improving usability should result in better coding rates.
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paper_title: Incidence and possible causes of prescribing potentially hazardous/contraindicated drug combinations in general practice.

paper_content:

BACKGROUND ::: Preventing the use of medications where there is the potential for serious drug-drug interactions or drug-disease interactions (contraindications) is essential to ensure patient safety. Previous studies have looked at the incidence of prescribing contraindicated drug combinations, but little is known about the underlying reasons for the co-prescribing events. The objectives of this study were to estimate the incidence of prescribing contraindicated drug combinations in general practice and to explore the clinical context, possible causes and potential systems failures leading to their occurrence. ::: ::: ::: METHODS ::: A list of contraindicated drug combinations was compiled according to established references. A search of computerised patient medication records was performed, followed by detailed chart review and assessment. The patient records from four general practices in an area of England were searched for a period of 1 year (1 June 1999-31 May 2000) to identify contraindicated drug combinations. All patients registered with the four participating practices during the study period were included (estimated n = 37 940). Medical records of the cases identified by the computer search were reviewed in detail and relevant information was extracted. Each case was then independently assessed by a pharmacist and a physician who judged whether the co-prescribing was justified and whether it was associated with an adverse drug event. Proximal causes and potential systems failures were suggested for each co-prescribing event. ::: ::: ::: MAIN OUTCOME MEASURES AND RESULTS ::: Fourteen patients with potential drug-drug interactions and 50 patients with potential drug-disease interactions were identified. Overall, these represent an incidence of 1.9 per 1000 patient-years (95% CI 1.5, 2.3) or 4.3 per 1000 patients being concurrently prescribed > or =2 drugs per year (95% CI 3.2, 5.4). 62 cases involving 63 co-prescribing events were reviewed. Two-thirds of these events involved medications that were initiated by hospital doctors. Awareness of the potential drug-drug or drug-disease interactions was documented in one-third of the events at the time of initial co-prescribing. Within the study period, the co-prescribing was judged to be not justified in 44 events (70%). Potential drug-drug interactions possibly resulted in two adverse drug events. The majority of contraindicated co-prescribing related to drug-disease interactions involved the use of propranolol or timolol eye drops for patients receiving bronchodilators and the use of amiodarone for patients receiving levothyroxine sodium. ::: ::: ::: CONCLUSION ::: The prescribing of contraindicated drug combinations was relatively rare in this study. Multiple possible causes and systems failures were identified and could be used to develop strategies for the prevention of prescribing errors involving contraindicated drug combinations in primary care.
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paper_title: Improving Acceptance of Computerized Prescribing Alerts in Ambulatory Care

paper_content:

Computerized drug prescribing alerts can improve patient safety, but are often overridden because of poor specificity and alert overload. Our objective was to improve clinician acceptance of drug alerts by designing a selective set of drug alerts for the ambulatory care setting and minimizing workflow disruptions by designating only critical to high-severity alerts to be interruptive to clinician workflow. The alerts were presented to clinicians using computerized prescribing within an electronic medical record in 31 Boston-area practices. There were 18,115 drug alerts generated during our six-month study period. Of these, 12,933 (71%) were noninterruptive and 5,182 (29%) interruptive. Of the 5,182 interruptive alerts, 67% were accepted. Reasons for overrides varied for each drug alert category and provided potentially useful information for future alert improvement. These data suggest that it is possible to design computerized prescribing decision support with high rates of alert recommendation acceptance by clinicians.
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paper_title: Using Commercial Knowledge Bases for Clinical Decision Support: Opportunities, Hurdles, and Recommendations

paper_content:

The quality and safety of health care leaves much to be desired.1,2 Automated clinical decision support (CDS) tools embedded in clinical information systems (CISs) such as computer provider order entry (CPOE) and electronic health records (EHR) applications have the potential to improve care and should be part of any comprehensive approach to improve quality.3,4,5,6 Medication prescribing is a component of health care with well documented quality and safety problems that can be improved by CDS.7,8,9 ::: ::: Medication-related CDS requires that pharmaceutical knowledge be represented in a computable, explicit and unambiguous form. Creating an automated representation of medical knowledge often is the most time consuming step in the development of a CDS system and is known as the “knowledge acquisition bottleneck.”10 For a time, it was hoped that the move toward explicit guidelines in medicine would decrease the knowledge acquisition effort,11 but that has not happened.12 Experiments on data sharing from over a decade ago have not progressed.13 As a result, just a few organizations, primarily academic medical centers, are creating rules and benefiting from CDS,14 but most health care organizations do not have the expertise or resources to create such knowledge bases themselves. ::: ::: One potential solution to the problem of access to automated medication-related knowledge is the set of commercial vendors that supply medication-related knowledge bases for pharmacy and prescribing applications. These vendors' products contain such knowledge as drug-drug and drug-disease interactions, minimum and maximum dosing suggestions, drug-allergy cross-sensitivity groupings, and groupings of medications by therapeutic class. Developers of CISs (either vendor-based or “homegrown”), with appropriate licensing, can incorporate commercial knowledge bases into their products. The knowledge base vendor receives a licensing fee for each CIS implementation and can amortize the …
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paper_title: Managing the alert process at NewYork-Presbyterian Hospital.

paper_content:

Clinical decision support can improve the quality of care, but requires substantial knowledge management activities. At NewYork-Presbyterian Hospital in New York City, we have implemented a formal alert management process whereby only hospital committees and departments can request alerts. An explicit requestor, who will help resolve the details of the alert logic and the alert message must be identified. Alerts must be requested in writing using a structured alert request form. Alert requests are reviewed by the Alert Committee and then forwarded to the Information Systems department for a software development estimate. The model required that clinical committees and departments become more actively involved in the development of alerts than had previously been necessary. In the 12 months following implementation, 10 alert requests were received. The model has been well received. A lot of the knowledge engineering work has been distributed and burden has been removed from scarce medical informatics resources.
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Title: Review Paper Medication-related Clinical Decision Support in Computerized Provider Order Entry Systems: A Review

Section 1: Introduction
Description 1: Introduce the paper, its purpose, and provide background information on medication use, clinical decision support (CDS), and computerized provider order entry (CPOE) systems.

Section 2: Drug-Allergy Checking
Description 2: Discuss the drug-allergy checking capabilities in CPOE systems, including features, challenges, and recommendations.

Section 3: Basic Dosing Guidance for Medications in CPOE
Description 3: Explore the importance of dosing guidance, common errors, and the role of CPOE systems in improving dosing accuracy.

Section 4: Formulary Decision Support
Description 4: Examine how CPOE systems provide formulary decision support, including methods, success factors, and recommendations.

Section 5: Duplicate Therapy Checking
Description 5: Describe duplicate therapy checking features, challenges, and the impact of CPOE systems on reducing medication duplication errors.

Section 6: Drug-Drug Interaction Checking
Description 6: Discuss the functionalities and limitations of drug-drug interaction checking in CPOE systems and their implications.

Section 7: Categories of Advanced Medication-related Decision Support
Description 7: Outline advanced medication-related decision support categories that should be considered after basic CDS is in place.

Section 8: Advanced Dosing Guidance in CPOE
Description 8: Detail advanced dosing guidance features specific to various patient populations and their impact on dosing accuracy.

Section 9: Advanced Guidance for Medication-associated Laboratory Testing
Description 9: Discuss the role of CPOE systems in facilitating medication-associated laboratory testing and monitoring.

Section 10: Advanced Checking of Drug-Disease Interactions and Contraindications
Description 10: Examine advanced drug-disease interaction checking features and the importance of capturing accurate patient conditions.

Section 11: Advanced Drug-Pregnancy Alerting
Description 11: Explore the implementation of drug-pregnancy alerting in CPOE systems and associated challenges.

Section 12: Recommendations for Future Work
Description 12: Provide detailed recommendations for various stakeholders on improving medication-related CDS.

Section 13: Summary
Description 13: Summarize the overall findings, importance, and future directions for medication-related CDS in CPOE systems.