Association of Hospital Public Quality Reporting With Electronic Health Record Medication Safety Performance.

Importance: Despite billions spent in public investment, electronic health records (EHRs) have not delivered on the promise of large quality and safety improvement. Simultaneously, there is debate on whether public quality reporting is a useful tool to incentivize quality improvement. Objective: To evaluate whether publicly reported feedback was associated with hospital improvement in an evaluation of medication-related clinical decision support (CDS) safety performance. Design, Settings, and Participants: This nonrandomized controlled trial included US hospitals that participated in the Computerized Provider Order Entry (CPOE) Evaluation Tool in the Leapfrog Hospital Survey, a national quality reporting program that evaluates safety performance of hospital CDS using simulated orders and patients, in 2017 to 2018. A sharp regression discontinuity design was used to identify the association of receiving negative feedback with hospital performance improvement in the subsequent year. Data were analyzed from January through September 2020. Exposures: Publicly reported quality feedback. Main Outcomes and Measures: The main outcome was improvement from 2017 to 2018 on the Leapfrog CPOE Evaluation Tool, using regression discontinuity model estimates of the association of receiving negative publicly reported feedback with quality improvement. Results: A total of 1183 hospitals were included, with a mean (SD) CPOE score of 59.3% (16.3%) at baseline. Hospitals receiving negative feedback improved 8.44 (95% CI, 0.09 to 16.80) percentage points more in the subsequent year compared with hospitals that received positive feedback on the same evaluation. This change was driven by differences in improvement in basic CDS capabilities (ß = 8.71 [95%CI, 1.67 to 18.73]) rather than advanced CDS (ß = 6.15 [95% CI, -9.11 to 26.83]). Conclusions and Relevance: In this nonrandomized controlled trial, publicly reported feedback was associated with quality improvement, suggesting targeted measurement and reporting of process quality may be an effective policy lever to encourage improvement in specific areas. Clinical decision support represents an important tool in ensuring patient safety and decreasing adverse drug events, especially for complex patients and those with multiple chronic conditions who often receive several different drugs during an episode of care.

Effect of the CRADLE vital signs alert device intervention on referrals for obstetric haemorrhage in low-middle income countries: a secondary analysis of a stepped- wedge cluster-randomised control trial.

BACKGROUND: Obstetric haemorrhage is the leading cause of maternal death worldwide, 99% of which occur in low and middle income countries. The majority of deaths and adverse events are associated with delays in identifying compromise and escalating care. Management of severely compromised pregnant women may require transfer to tertiary centres for specialised treatment, therefore early recognition is vital for efficient management. The CRADLE vital signs alert device accurately measures blood pressure and heart rate, calculates the shock index (heart rate divided by systolic blood pressure) and alerts the user to compromise through a traffic light system reflecting previously validated shock index thresholds. METHODS: This is a planned secondary analysis of data from the CRADLE-3 trial from ten clusters across Africa, India and Haiti where the device and training package were randomly introduced. Referral data were prospectively collected for a 4-week period before, and a 4-week period 3 months after implementation. Referrals from primary or secondary care facilities to higher level care for any cause were recorded. The denominator was the number of women seen for maternity care in these facilities. RESULTS: Between April 1 2016 and Nov 30th, 2017 536,223 women attended maternity care facilities. Overall, 3.7% (n = 2784/74,828) of women seen in peripheral maternity facilities were referred to higher level care in the control period compared to 4.4% (n = 3212/73,371) in the intervention period (OR 0.89; 0.39-2.05) (data for nine sites that were able to collect denominator). Of these 0.29% (n = 212) pre-intervention and 0.16% (n = 120) post-intervention were referred to higher-level facilities for maternal haemorrhage. Although overall referrals did not significantly reduce there was a significant reduction in referrals for obstetric haemorrhage (OR 0.56 (0.39-0.65) following introduction of the device with homogeneity (i-squared 26.1) between sites. There was no increase in any bleeding-related morbidity (maternal death or emergency hysterectomy). CONCLUSIONS: Referrals for obstetric haemorrhage reduced following implementation of the CRADLE Vital Signs Alert Device, occurring without an increase in maternal death or emergency hysterectomy. This demonstrates the potential benefit of shock index in management pathways for obstetric haemorrhage and targeting limited resources in low- middle- income settings. TRIAL REGISTRATION: This study is registered with the ISRCTN registry, number ISRCTN41244132 (02/02/2016).

Optimizing pharmacists' detection of prescribing errors: Comparison of on-ward and central pharmacy services.

WHAT IS KNOWN AND OBJECTIVE: Prescribing errors are the leading cause of adverse drug events in hospitalized patients. Pharmaceutical validation, defined as the review of drug orders by a pharmacist, associated with clinical decision support (CDS) systems, significantly reduces these errors and adverse drug events. In Belgium, because clinical pharmacy services have limited public financial support, most pharmaceutical validations are performed at the central pharmacy instead of on-ward, by hospital pharmacists doing dispensing activities. In that context, we aimed at evaluating whether the strategy of CDS-guided central validation was the most appropriate method to improve the quality and safety of medicines' use compared to an on-ward pharmaceutical validation. METHODS: Our retrospective observational study was conducted in a Belgian tertiary care hospital, in 2018-2019. Data were extracted from our validation software and pharmacists' charts. The outcomes of the study were the number of pharmaceutical interventions due to the detection of prescribing errors, reasons for interventions, their acceptance rate and their potential clinical impact (according to two blinded experts) in the central pharmacy and on-ward validation groups. RESULTS AND DISCUSSION: Despite the use of the same CDS, a pharmaceutical intervention following the detection of a prescribing error was made for 2.9% (20/698) of central group patients and 13.3% (93/701) of on-ward patients (χ2  = 49.97, p < 0.001). Interventions made at the central pharmacy (n = 20) mostly relied on CDS-alerts (i.e. drug-drug interaction [25%] or overdosing [20%]) while interventions made on-ward (n = 93) were also for pharmacotherapy optimization (i.e. no valid indication [25%] or inappropriate drug's choice [11%]). The on-ward validation group showed a higher acceptance rate compared to the central group (84% and 65%, respectively [Fisher's test, p = 0.053]). Proportions of interventions with significant or very significant clinical impact were similar between the two groups but as fewer interventions were made centrally, a significant proportion of errors were probably not detected by the central validation. WHAT IS NEW AND CONCLUSION: On-ward pharmaceutical validation leads to a higher rate of prescribing error detection. Pharmaceutical interventions made by on-ward pharmacists are also better accepted and more relevant, going further than CDS-alerts.

Impact of computerised physician order entry (CPOE) on the incidence of chemotherapy-related medication errors: a systematic review.

PURPOSE: Computerised prescriber (or physician) order entry (CPOE) implementation is one of the strategies to reduce medication errors. The extent to which CPOE influences the incidence of chemotherapy-related medication errors (CMEs) was not previously collated and systematically reviewed. Hence, this study was designed to collect, collate, and systematically review studies to evaluate the effect of CPOE on the incidence of CMEs. METHODS: A search was performed of four databases from 1 January 1995 until 1 August 2019. English-language studies evaluating the effect of CPOE on CMEs were selected as per inclusion and exclusion criteria. The total CMEs normalised to total prescriptions pre- and post-CPOE were extracted and collated to perform a meta-analysis using the 'meta' package in R. The systematic review was registered with PROSPERO CRD42018104220. RESULTS: The database search identified 1621 studies. After screening, 19 studies were selected for full-text review, of which 11 studies fulfilled the selection criteria. The meta-analysis of eight studies with a random effects model showed a risk ratio of 0.19 (95% confidence interval: 0.08-0.44) favouring CPOE (I2 = 99%). CONCLUSION: The studies have shown consistent reduction in CMEs after CPOE implementation, except one study that showed an increase in CMEs. The random effects model in the meta-analysis of eight studies showed that CPOE implementation reduced CMEs by 81%.

Trends in the use of computerized physician order entry by health-system affiliated ambulatory clinics in the United States, 2014-2016.

BACKGROUND: Computerized provider order entry (CPOE) can help providers deliver better quality care. We aimed to understand recent trends in use of CPOE by health system-affiliated ambulatory clinics. METHODS: We analyzed longitudinal data (2014-2016) for 19,109 ambulatory clinics that participated in all 3 years of the Healthcare Information and Management Systems Society Analytics survey to assess use of CPOE and identify characteristics of clinics associated with CPOE use. We calculated descriptive statistics to examine overall trends in use, location of order entry (bedside vs. clinical station), and system-level use CPOE across all clinics. We used linear probability models to explore the association between clinic characteristics (practice size, practice type, and health system type) and two outcomes of interest: CPOE use at any point between 2014 and 2016, and CPOE use beginning in 2015 or 2016. RESULTS: Between 2014 and 2016, use of CPOE increased more than 9 percentage points from 58 to 67%. Larger clinics and those affiliated with multi-hospital health systems were more likely to have reported use of CPOE. We found no difference in CPOE use by primary care versus specialty care clinics. When used, most clinics reported using CPOE for most or all of their orders. Health systems that used CPOE usually did so for all system-affiliated clinics. CONCLUSIONS: Small practice size or not being part of a multi-hospital system are associated with lower use of CPOE between 2014 and 2016. Less than optimal use in these environments may be harming patient outcomes.

A Clinical Reminder Order Check Intervention to Improve Guideline-concordant Imaging Practices for Men With Prostate Cancer: A Pilot Study.

OBJECTIVE: To understand how to potentially improve inappropriate prostate cancer imaging rates we used National Comprehensive Cancer Network's guidelines to design and implement a Clinical Reminder Order Check (CROC) that alerts ordering providers of potentially inappropriate imaging orders in real-time based on patient features of men diagnosed with low-risk prostate cancer. METHODS: We implemented the CROC at VA New York Harbor Healthcare System from April 2, 2015 to November 15, 2017. We then used VA administrative claims from the VA's Corporate Data Warehouse to analyze imaging rates among men with low-risk prostate cancer at VA New York Harbor Healthcare System before and after CROC implementation. We also collected and cataloged provider responses in response to overriding the CROC in qualitative analysis. RESULTS FIFTY SEVEN PERCENT: (117/205) of Veterans before CROC installation and 73% (61/83) of Veterans post-intervention with low-risk prostate cancer received guideline-concordant care. CONCLUSION: While the decrease in inappropriate imaging during our study window was almost certainly due to many factors, a Computerized Patient Record System-based CROC intervention is likely associated with at least moderate improvement in guideline-concordant imaging practices for Veterans with low-risk prostate cancer.

National Trends in the Safety Performance of Electronic Health Record Systems From 2009 to 2018.

Importance: Despite the broad adoption of electronic health record (EHR) systems across the continuum of care, safety problems persist. Objective: To measure the safety performance of operational EHRs in hospitals across the country during a 10-year period. Design, Setting, and Participants: This case series included all US adult hospitals nationwide that used the National Quality Forum Health IT Safety Measure EHR computerized physician order entry safety test administered by the Leapfrog Group between 2009 and 2018. Data were analyzed from July 1, 2018 to December 1, 2019. Exposure: The Health IT Safety Measure test, which uses simulated medication orders that have either injured or killed patients previously to evaluate how well hospital EHRs could identify medication errors with potential for patient harm. Main Outcomes and Measures: Descriptive statistics for performance on the assessment test over time were calculated at the overall test score level, type of decision support category level, and EHR vendor level. Results: Among 8657 hospital-years observed during the study, mean (SD) scores on the overall test increased from 53.9% (18.3%) in 2009 to 65.6% (15.4%) in 2018. Mean (SD) hospital score for the categories representing basic clinical decision support increased from 69.8% (20.8%) in 2009 to 85.6% (14.9%) in 2018. For the categories representing advanced clinical decision support, the mean (SD) score increased from 29.6% (22.4%) in 2009 to 46.1% (21.6%) in 2018. There was considerable variation in test performance by EHR. Conclusions and Relevance: These findings suggest that despite broad adoption and optimization of EHR systems in hospitals, wide variation in the safety performance of operational EHR systems remains across a large sample of hospitals and EHR vendors. Hospitals using some EHR vendors had significantly higher test scores. Overall, substantial safety risk persists in current hospital EHR systems.

Enteral and Parenteral Order Writing Survey-A Collaborative Evaluation Between the Academy of Nutrition and Dietetics' Dietitians in Nutrition Support Dietetics Practice Group and the American Society for Parenteral and Enteral Nutrition (ASPEN) Dietetics Practice Section.

INTRODUCTION: In 2014 and 2017, the Centers for Medicare and Medicaid Services authorized nutrition-related ordering privileges for registered dietitian nutritionists (RDNs) in hospital and long-term care settings, respectively. Despite this practice advancement, information describing current parenteral nutrition (PN) and enteral nutrition (EN) ordering practices is lacking. Dietitians in Nutrition Support, a dietetic practice group of the Academy of Nutrition and Dietetics and the Dietetics Practice Section of the American Society of Parenteral and Enteral Nutrition (ASPEN) utilized a survey to describe PN and EN ordering practices among RDNs in the United States. METHODS: A cross-sectional study design was utilized to describe RDN PN and EN ordering privileges. Respondents were asked to describe PN and EN ordering privileges, primary practice setting, primary patient population served, nutrition specialty certification, highest degree earned, career length, and, if applicable, the nature of prior denials for ordering privileges or reasons for not applying for ordering privileges. RESULTS: Seven hundred two RDNs completed the survey (12% response rate), with 664 RDNs providing complete data. The majority of respondents (n=558) cared for adult/geriatric patients. Among this subset, 47% had no PN ordering privileges; 14% could order and sign PN; 28% could order PN with provider cosignature; and 10% could order partial PN with provider cosignature. Nineteen percent of RDNs had no EN ordering privileges; 37% could order and sign EN; and 44% could order EN with provider cosignature. RDNs with ordering privileges were more likely to have a nutrition specialty certification and work in an academic or community hospital setting. CONCLUSION: PN and EN ordering privileges are varied because of institution and state requirements. Future research describing the outcomes associated with RDN ordering privileges is needed. This article has been approved by the Academy's Research, International, and Scientific Affairs team and Council on Research and the ASPEN Board of Directors. This article has been co-published with permission in Nutrition in Clinical Practice. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. Either citation can be used when citing this article.

The Influence of an Electronic Medical Record Embedded Best Practice Alert on Rate of Hospital Acquired Catheter Associated Urinary Tract Infections: Do Best Practice Alerts Reduce CAUTIs?

OBJECTIVE: To understand if an electronic medical record embedded best practice alert decreased our hospital's Catheter-associated urinary tract infections (CAUTIs) and catheter utilization (CU) rates. METHODS: Data from our inpatient prospective CAUTI database, spanning 2011 to 2016, were utilized for our analysis with the Best Practice Alert (BPA) starting in 2013. Using generalized linear models we compared the CU and CAUTI rates between pre- and post-BPA periods in different patient subpopulations. RESULTS: We identified no decrease in the CU rate and no effect on the CAUTI rates as a result of the BPA. However, there was an increase in CAUTI rates in our adult intensive care unit (ICU) population from 0.2 to 1.8 CAUTIs per 1,000 catheter days (P <.01) despite a significant decrease in CU rate within this population after the BPA (pre-BPA odds ratio [OR] 0.93 vs post-BPA OR 0.89; P <0.01). In contrast, our non-ICU adult population had a decrease in CAUTI rate from 2.8 to 1.7 CAUTIs per 1,000 catheter days (P <.01) despite no significant decrease after the BPA (pre-BPA OR 0.90 vs post-BPA OR 0.95; P <.1). CONCLUSION: CAUTI rates are exceedingly low, with or without the use of a BPA. Such an alert appears to have limited success in lowering CU rates in populations where catheter use is already low and may not always lead to an improvement in CAUTI rates as there appears to be some populations that may be more prone to CAUTI development secondary to possible intrinsic or co-morbid conditions.

Predicting Inpatient Medication Orders From Electronic Health Record Data.

In a general inpatient population, we predicted patient-specific medication orders based on structured information in the electronic health record (EHR). Data on over three million medication orders from an academic medical center were used to train two machine-learning models: A deep learning sequence model and a logistic regression model. Both were compared with a baseline that ranked the most frequently ordered medications based on a patient's discharge hospital service and amount of time since admission. Models were trained to predict from 990 possible medications at the time of order entry. Fifty-five percent of medications ordered by physicians were ranked in the sequence model's top-10 predictions (logistic model: 49%) and 75% ranked in the top-25 (logistic model: 69%). Ninety-three percent of the sequence model's top-10 prediction sets contained at least one medication that physicians ordered within the next day. These findings demonstrate that medication orders can be predicted from information present in the EHR.

Assessment of Unintentional Duplicate Orders by Emergency Department Clinicians Before and After Implementation of a Visual Aid in the Electronic Health Record Ordering System.

Importance: Electronic health records allow teams of clinicians to simultaneously care for patients, but an unintended consequence is the potential for duplicate orders of tests and medications. Objective: To determine whether a simple visual aid is associated with a reduction in duplicate ordering of tests and medications. Design, Setting, and Participants: This cohort study used an interrupted time series model to analyze 184 694 consecutive patients who visited the emergency department (ED) of an academic hospital with 55 000 ED visits annually. Patient visits occurred 1 year before and after each intervention, as follows: for laboratory orders, from August 13, 2012, to August 13, 2014; for medication orders, from February 3, 2013, to February 3, 2015; and for radiology orders, from December 12, 2013, to December 12, 2015. Data were analyzed from April to September 2019. Exposure: If an order had previously been placed during the ED visit, a red highlight appeared around the checkbox of that order in the computerized provider order entry system. Main Outcomes and Measures: Number of unintentional duplicate laboratory, medication, and radiology orders. Results: A total of 184 694 patients (mean [SD] age, 51.6 [20.8] years; age range, 0-113.0 years; 99 735 [54.0%] women) who visited the ED were analyzed over the 3 overlapping study periods. After deployment of a noninterruptive nudge in electronic health records, there was an associated 49% decrease in the rate of unintentional duplicate orders for laboratory tests (incidence rate ratio, 0.51; 95% CI, 0.45-0.59), from 4485 to 2731 orders, and an associated 40% decrease in unintentional duplicate orders of radiology tests (incidence rate ratio, 0.60; 95% CI, 0.44-0.82), from 956 to 782 orders. There was not a statistically significant change in unintentional duplicate orders of medications (incidence rate ratio, 1.17; 95% CI, 0.52-2.61), which increased from 225 to 287 orders. The nudge eliminated an estimated 17 936 clicks in our electronic health record. Conclusions and Relevance: In this interrupted time series cohort study, passive visual cues that provided just-in-time decision support were associated with reductions in unintentional duplicate orders for laboratory and radiology tests but not in unintentional duplicate medication orders.

The Effect of Eliminating Intermediate Severity Drug-Drug Interaction Alerts on Overall Medication Alert Burden and Acceptance Rate.

OBJECTIVE: This study aimed to determine the effects of reducing the number of drug-drug interaction (DDI) alerts in an order entry system. METHODS: Retrospective pre-post analysis at an urban medical center of the rates of medication alerts and alert acceptance during a 5-month period before and 5-month period after the threshold for firing DDI alerts was changed from "intermediate" to "severe." To ensure that we could determine varying response to each alert type, we took an in-depth look at orders generating single alerts. RESULTS: Before the intervention, 241,915 medication orders were placed, of which 25.6% generated one or more medication alerts; 5.3% of the alerts were accepted. During the postintervention period, 245,757 medication orders were placed of which 16.0% generated one or more medication alerts, a 37.5% relative decrease in alert rate (95% confidence interval [CI]: -38.4 to -36.8%), but only a 9.6% absolute decrease (95% CI: -9.4 to -9.9%). 7.4% of orders generating alerts were accepted postintervention, a 39.6% relative increase in acceptance rate (95% CI: 33.2-47.2%), but only a 2.1% absolute increase (95% CI: 1.8-2.4%). When only orders generating a single medication alert were considered, there was a 69.1% relative decrease in the number of orders generating DDI alerts, and an 85.7% relative increase in the acceptance rate (95% CI: 58.6-126.2%), though only a 1.8% absolute increase (95% CI: 1.3-2.3%). CONCLUSION: Eliminating intermediate severity DDI alerts resulted in a statistically significant decrease in alert burden and increase in the rate of medication alert acceptance, but alert acceptance remained low overall.

Evaluating the Impact of Interruptive Alerts within a Health System: Use, Response Time, and Cumulative Time Burden.

BACKGROUND: Health systems often employ interruptive alerts through the electronic health record to improve patient care. However, concerns of "alert fatigue" have been raised, highlighting the importance of understanding the time burden and impact of these alerts on providers. OBJECTIVES: Our main objective was to determine the total time providers spent on interruptive alerts in both inpatient and outpatient settings. Our secondary objectives were to analyze dwell time for individual alerts and examine both provider and alert-related factors associated with dwell time variance. METHODS: We retrospectively evaluated use and response to the 75 most common interruptive ("popup") alerts between June 1st, 2015 and November 1st, 2016 in a large academic health care system. Alert "dwell time" was calculated as the time between the alert appearing on a provider's screen until it was closed. The total number of alerts and dwell times per provider per month was calculated for inpatient and outpatient alerts and compared across alert type. RESULTS: The median number of alerts seen by a provider was 12 per month (IQR 4-34). Overall, 67% of inpatient and 39% of outpatient alerts were closed in under 3 seconds. Alerts related to patient safety and those requiring more than a single click to proceed had significantly longer median dwell times of 5.2 and 6.7 seconds, respectively. The median total monthly time spent by providers viewing alerts was 49 seconds on inpatient alerts and 28 seconds on outpatient alerts. CONCLUSION: Most alerts were closed in under 3 seconds and a provider's total time spent on alerts was less than 1 min/mo. Alert fatigue may lie in their interruptive and noncritical nature rather than time burden. Monitoring alert interaction time can function as a valuable metric to assess the impact of alerts on workflow and potentially identify routinely ignored alerts.

Ease of ordering high- and low-value services in various electronic health records.

OBJECTIVES: The use of electronic health record (EHR) systems by US clinicians is nearly ubiquitous. One motivation for EHR implementation is the ability to increase provider efficiency and improve patient-centered outcomes. There are no data examining how EHR design aligns with the ordering of high- and low-value clinical services. STUDY DESIGN: A survey of outpatient providers utilizing various EHR systems. METHODS: Five high-value and 5 low-value services that would typically be ordered in a primary care setting were identified. Providers using different EHR systems quantified the number of computer clicks required to order each service. RESULTS: Five unique EHR systems representing those used by nearly two-thirds of health systems were included. No correlation was found between the ease of EHR ordering and the value of the clinical service. Three of the 5 services that were easiest to order were low value, and 3 high-value services were among the most difficult to order. CONCLUSIONS: In EHR systems used nationwide, no association existed between the clinical value of a service and the ease of ordering. This disconnect suggests that EHR redesign can significantly improve clinician workflow to facilitate the use of more high-value care and fewer low-value services.

Analysis of dosing-button compliance.

PURPOSE: A project was undertaken at an academic medical center to assess use of available dosing buttons within the computerized provider-order-entry (CPOE) system in order to identify opportunities for optimization of medication builds. METHODS: A retrospective observational study was conducted to identify medication records within a CPOE system meeting prespecified inclusion and exclusion criteria. A report capturing all inpatient adult medication orders associated with the identified medication records over a 6-month period was generated. The primary endpoint was percent dosing-button compliance, calculated as the number of orders with doses consistent with existing dosing-button options divided by the total number of orders during the study period. Secondary study objectives included a comparison of high- and low-performing medication record samples and identification of potential reasons for lack of dosing-button use. RESULTS: A total of 2,506 CPOE medication records associated with a total of 694,877 medication orders entered during the study period were analyzed. Median percent dosing-button compliance was 99.92% (interquartile range, 83.33-100%). High-performing records (n = 1243) were more likely to be associated with anti-infective medications (p = 0.041) and medications not on formulary at the study institution (p < 0.001). Medications in the sample of poor-performing CPOE records (n = 614) were more likely to be agents delivered via the i.v. route (p < 0.001). There were 45 records for which poor dosing-button compliance was attributed to lack of a clinically reasonable dosing option. CONCLUSION: A high level of dosing-button compliance was demonstrated despite the lack of routine revalidation of dosing buttons after initial medication builds. Some opportunity for optimization was identified during the project, which established a quality assurance method to facilitate future auditing of medication builds.

A Comparison of One- and Four-Open-Chart Access: No Change in Computerized Provider Order Entry Error Rates.

OBJECTIVE: To assess changes in computerized provider order entry error rates among providers who with less than 24-hour notice were switched from four-chart access to one-chart-only access. METHODS: An interrupted time series analysis of emergency medicine providers, hospitalists, and maternal child health providers was performed with pairwise comparison of computerized provider order entry error rates within and between specialties. This retrospective snapshot consisted of four phases. Phase 1 was the baseline 2 weeks where providers were privileged to work with up to four charts open. Phase 2 was the 2-week period where providers were limited to one-chart access. Phase 3 was the 2-week period where providers were returned to four-chart access. And phase 4 was a 2-week period 3 months following the end of phase 3. RESULTS: Analysis of the overall and specialty-stratified cohorts revealed no statistically significant differences in median computerized provider order entry error rates across the four phases (Wilcoxon signed-rank test, α = 0.05). However, statistically significant differences in median computerized provider order entry error rates were detected between the three specialties within each phase of the study (Kruskal-Wallis, p < 0.001). CONCLUSION: Allowing providers in select specialties to have access to four charts simultaneously does not increase their computerized provider order entry error rates. Significant differences in error rates between specialties suggest the need for further study of the use of standardized order sets, charting, and workflow variations.

Optimising computerised decision support to transform medication safety and reduce prescriber burden: study protocol for a mixed-methods evaluation of drug-drug interaction alerts.

INTRODUCTION: Drug-drug interaction (DDI) alerts in hospital electronic medication management (EMM) systems are generated at the point of prescribing to warn doctors about potential interactions in their patients' medication orders. This project aims to determine the impact of DDI alerts on DDI rates and on patient harm in the inpatient setting. It also aims to identify barriers and facilitators to optimal use of alerts, quantify the alert burden posed to prescribers with implementation of DDI alerts and to develop algorithms to improve the specificity of DDI alerting systems. METHODS AND ANALYSIS: A controlled pre-post design will be used. Study sites include six major referral hospitals in two Australian states, New South Wales and Queensland. Three hospitals will act as control sites and will implement an EMM system without DDI alerts, and three as intervention sites with DDI alerts. The medical records of 280 patients admitted in the 6 months prior to and 6 months following implementation of the EMM system at each site (total 3360 patients) will be retrospectively reviewed by study pharmacists to identify potential DDIs, clinically relevant DDIs and associated patient harm. To identify barriers and facilitators to optimal use of alerts, 10-15 doctors working at each intervention hospital will take part in observations and interviews. Non-identifiable DDI alert data will be extracted from EMM systems 6-12 months after system implementation in order to quantify alert burden on prescribers. Finally, data collected from chart review and EMM systems will be linked with clinically relevant DDIs to inform the development of algorithms to trigger only clinically relevant DDI alerts in EMM systems. ETHICS AND DISSEMINATION: This research was approved by the Hunter New England Human Research Ethics Committee (18/02/21/4.07). Study results will be published in peer-reviewed journals and presented at local and international conferences and workshops.

Improving the medication-use process for 23.4% sodium chloride.

PURPOSE: Results of a study to evaluate medication storage, distribution, and safety outcomes after addition of 23.4% sodium chloride to a hospital formulary and development of a novel distribution process incorporating safeguards allowing for urgent medication removal from an automated dispensing cabinet (ADC) are reported. SUMMARY: A retrospective review of 23.4% sodium chloride injection doses dispensed during a 38-month period was performed at an academic medical center to evaluate times from order entry to pharmacist verification, dispensing, and administration; adverse events related to dispensing or administration; and other outcomes. Seventy doses of 23.4% sodium chloride injection were administered to 60 patients during the study period. The mean times from order entry to pharmacist verification, medication removal from an ADC, and administration were 8, 25, and 43 minutes, respectively, when the ADC override function was not used. After 23.4% sodium chloride injection's addition to the ADC override list, 16 of 30 doses were removed "on override," with order entry performed retrospectively for 9 of these doses. There were no documented adverse events related to medication distribution and 2 adverse effects possibly related to medication administration. CONCLUSION: Novel storage and distribution processes for 23.4% sodium chloride injection were implemented at a large academic medical center to optimize safety related to the medication-use process. A retrospective review of 70 administered doses found the process of maintaining this medication in ADCs to be a safe and efficient method of storing and dispensing a high-alert medication.

Computerized Physician Order Entry in the Neonatal Intensive Care Unit: A Narrative Review.

BACKGROUND: Computerized physician order entry (CPOE) has grown since the early 1990s. While many systems serve adult patients, systems for pediatric and neonatal populations have lagged. Adapting adult CPOE systems for pediatric use may require significant modifications to address complexities associated with pediatric care such as daily weight changes and small medication doses. OBJECTIVE: This article aims to review the neonatal intensive care unit (NICU) CPOE literature to characterize trends in the introduction of this technology and to identify potential areas for further research. METHODS: Articles pertaining to NICU CPOE were identified in MEDLINE using MeSH terms "medical order entry systems," "drug therapy," "intensive care unit, neonatal," "infant, newborn," etc. Two physician reviewers evaluated each article for inclusion and exclusion criteria. Consensus judgments were used to classify the articles into five categories: medication safety, usability/alerts, clinical practice, clinical decision Support (CDS), and implementation. Articles addressing pediatric (nonneonatal) CPOE were included if they were applicable to the NICU setting. RESULTS: Sixty-nine articles were identified using MeSH search criteria. Twenty-two additional articles were identified by hand-searching bibliographies and 6 articles were added after the review process. Fifty-five articles met exclusion criteria, for a final set of 42 articles. Medication safety was the focus of 22 articles, followed by clinical practice (10), CDS (10), implementation (11), and usability/alerts (4). Several addressed more than one category. No study showed a decrease in medication safety post-CPOE implementation. Within clinical practice articles, CPOE implementation showed no effect on blood glucose levels or time to antibiotic administration but showed conflicting results on mortality rates. Implementation studies were largely descriptive of single-hospital experiences. CONCLUSION: CPOE implementation within the NICU has demonstrated improvement in medication safety, with the most consistent benefit involving a reduction in medication errors and wrong-time administration errors. Additional research is needed to understand the potential limitations of CPOE systems in neonatal intensive care and how CPOE affects mortality.

How often do prescribers include indications in drug orders? Analysis of 4 million outpatient prescriptions.

PURPOSE: To examine the extent to which outpatient clinicians currently document drug indications in prescription instructions. METHODS: Free-text sigs were extracted from all outpatient prescriptions generated by the computerized prescriber order entry system of a major academic institution during a 5-year period. Natural language processing was used to identify drug indications. The data set was analyzed to determine the rates at which prescribers included indications. It was stratified by provider specialty, drug class, and specific medications, to determine how often these indications were in prescriptions for as-needed (PRN) versus non-PRN medications. RESULTS: During the study period, 4,356,086 prescriptions were ordered. Indications were included in 322,961 orders (7.41%). From these orders, 249,262 indications (77.18%) were written for PRN orders. Although internal medicine prescribers generated the highest number of medication orders, they included indications in only 6.26% of their prescriptions, whereas orthopedic surgery providers had the highest rate of documenting indications (33.41%). Pain was the most common indication, accounting for 30.35% of all documented indications. The drug class with the highest number of sigs-containing indications was narcotic analgesics. Non-PRN chronic medication prescriptions rarely included the indication. CONCLUSION: Prescribers rarely included drug indications in electronic free-text prescription instructions, and, when they did, it was mostly for PRN uses such as pain.