Medication Safety in Two Intensive Care Units of a Community Teaching Hospital After Electronic Health Record Implementation: Sociotechnical and Human Factors Engineering Considerations.

OBJECTIVE: The aim of the study was to assess the impact of Electronic Health Record (EHR) implementation on medication safety in two intensive care units (ICUs). METHODS: Using a prospective pre-post design, we assessed 1254 consecutive admissions to two ICUs before and after an EHR implementation. Each medication event was evaluated with regard to medication error (error type, medication-management stage) and impact on patient (severity of potential or actual harm). RESULTS: We identified 4063 medication-related events either pre-implementation (2074 events) or post-implementation (1989 events). Although the overall potential for harm due to medication errors decreased post-implementation only 2 of the 3 error rates were significantly lower post-implementation. After EHR implementation, we observed reductions in rates of medication errors per admission at the stages of transcription (0.13-0, P < 0.001), dispensing (0.49-0.16, P < 0.001), and administration (0.83-0.56, P = 0.011). Within the ordering stage, 4 error types decreased post-implementation (orders with omitted information, error-prone abbreviations, illegible orders, failure to renew orders) and 4 error types increased post-implementation (orders of wrong drug, orders containing a wrong start or stop time, duplicate orders, orders with inappropriate or wrong information). Within the administration stage, we observed a reduction of late administrations and increases in omitted administrations and incorrect documentation. CONCLUSIONS: Electronic Health Record implementation in two ICUs was associated with both improvement and worsening in rates of specific error types. Further safety improvements require a nuanced understanding of how various error types are influenced by the technology and the sociotechnical work system of the technology implementation. Recommendations based on human factors engineering principles are provided for reducing medication errors.

Beta-lactam versus beta- lactam/macrolide therapy in pediatric outpatient pneumonia.

OBJECTIVE: The objective was to evaluate the comparative effectiveness of beta-lactam monotherapy and beta- lactam/macrolide combination therapy in the outpatient management of children with community-acquired pneumonia (CAP). METHODS: This retrospective cohort study included children, ages 1-18 years, with CAP diagnosed between January 1, 2008 and January 31, 2010 during outpatient management in the Geisinger Health System. The primary exposure was receipt of beta-lactam monotherapy or beta-lactam/macrolide combination therapy. The primary outcome was treatment failure, defined as a follow-up visit within 14 days of diagnosis resulting in a change in antibiotic therapy. Logistic regression within a propensity score- restricted cohort was used to estimate the likelihood of treatment failure. RESULTS: Of 717 children in the analytical cohort, 570 (79.4%) received beta-lactam monotherapy and 147 (20.1%) received combination therapy. Of those who received combination therapy 58.2% of children were under 6 years of age. Treatment failure occurred in 55 (7.7%) children, including in 8.1% of monotherapy recipients, and 6.1% of combination therapy recipients. Treatment failure rates were highest in children 6-18 years receiving monotherapy (12.9%) and lowest in children 6-18 years receiving combination therapy (4.0%). Children 6-18 years of age who received combination therapy were less likely to fail treatment than those who received beta-lactam monotherapy (propensity-adjusted odds ratio, 0.51; 95% confidence interval, 0.28, 0.95). CONCLUSION: Children 6-18 years of age who received beta- lactam/macrolide combination therapy for CAP in the outpatient setting had lower odds of treatment failure compared with those who received beta-lactam monotherapy.

Adjunct Systemic Corticosteroid Therapy in Children With Community-Acquired Pneumonia in the Outpatient Setting.

BACKGROUND: The role of adjunct systemic corticosteroid therapy in children with community-acquired pneumonia (CAP) is not known. The objective was to determine the association between adjunct systemic corticosteroid therapy and treatment failure in children who received antibiotics for treatment of CAP in the outpatient setting. METHODS: The study included a retrospective cohort study of children, aged 1-18 years, with a diagnosis of CAP who were managed at an outpatient practice affiliated with Geisinger Health System from January 1, 2008 to January 31, 2010. The primary exposure was the receipt of adjunct corticosteroid therapy. The primary outcome was treatment failure defined as a respiratory-associated follow-up within 14 days of diagnosis in which the participant received a change in antibiotic therapy. The probability of receiving adjunct systemic corticosteroid therapy was calculated using a matched propensity score. A multivariable conditional logistic regression model was used to estimate the association between adjunct corticosteroids and treatment failure. RESULTS: Of 2244 children with CAP, 293 (13%) received adjunct corticosteroids, 517 (23%) had underlying asthma, and 624 (28%) presented with wheezing. Most patients received macrolide monotherapy for their CAP diagnosis (n = 1329; 59%). Overall, treatment failure was not associated with adjunct corticosteroid treatment (odds ratio [OR], 1.72; 95% confidence interval [CI], 0.93 and 3.19), but the association was statistically significant among patients with no history of asthma (OR, 2.38; 95% CI, 1.03 and 5.52), with no statistical association among patients with a history of asthma. CONCLUSION: Adjunct corticosteroid therapy was associated with treatment failure among children diagnosed with CAP who did not have underlying asthma.

Comparative Effectiveness of Beta-lactam Versus Macrolide Monotherapy in Children with Pneumonia Diagnosed in the Outpatient Setting.

BACKGROUND: Most children diagnosed with community-acquired pneumonia (CAP) are treated in the outpatient setting. The objective of this study was to determine the comparative clinical effectiveness of beta-lactam monotherapy and macrolide monotherapy in this population. STUDY DESIGN: Children, 1-18 years old, with a clinical diagnosis of CAP at an outpatient practice affiliated (n = 71) with Geisinger Health System during January 1, 2008 to January 31, 2010 were eligible. The primary exposure was receipt of beta-lactam or macrolide monotherapy. The primary outcome was treatment failure defined as change in antibiotic prescription within 14 days of the initial pneumonia diagnosis. Propensity scores were used to determine the likelihood of receiving macrolide monotherapy. Treatment groups were matched 1:1, based on propensity score, age group and asthma status. Multivariable conditional logistic regression models estimated the association between macrolide monotherapy and treatment failures. RESULTS: Of 1999 children with CAP, 1164 were matched. In the matched cohorts, 24% of children had asthma. Patients who received macrolide monotherapy had no statistical difference in treatment failure regardless of age when compared with patients who received beta-lactam monotherapy. CONCLUSION: Our findings suggest that children diagnosed with CAP in the outpatient setting and treated with beta-lactam or macrolide monotherapy have the same likelihood to fail treatment regardless of age.

Characterising the complexity of medication safety using a human factors approach: an observational study in two intensive care units.

OBJECTIVE: To examine medication safety in two intensive care units (ICU), and to assess the complexity of medication errors and adverse drug events (ADE) in ICUs across the stages of the medication-management process. METHODS: Four trained nurse data collectors gathered data on medication errors and ADEs between October 2006 and March 2007. Patient care documents (eg, medication order sheets, notes) and incident reports were used to identify medication errors and ADEs in a 24-bed adult medical/surgical ICU and an 18-bed cardiac ICU in a tertiary care, community teaching hospital. In this cross-sectional study, a total of 630 consecutive ICU patient admissions were assessed to produce data on the number, rates and types of potential and preventable ADEs across stages of the medication-management process. RESULTS: An average of 2.9 preventable or potential ADEs occurred in each admission, that is, 0.4 events per patient-day. Preventable or potential ADEs occurred in 2.6% of the medication orders. The rate of potential ADEs per 1000 patient-days was 276, whereas the rate of preventable ADEs per 1000 patient-days was 9.2. Most medication errors occur at the ordering (32%) and administration stages (39%). In 16-24% of potential and preventable ADEs, clusters of errors occurred either as a sequence of errors (eg, delay in medication dispensing leading to delay in medication administration) or grouped errors (eg, route and frequency errors in the order for a medication). Many of the sequences led to administration errors that were caused by errors earlier in the medication-management process. CONCLUSIONS: Understanding the complexity of the vulnerabilities of the medication-management process is important to devise solutions to improve patient safety. Electronic health record technology with computerised physician order entry may be one step necessary to improve medication safety in ICUs. Solutions that target multiple stages of the medication-management process are necessary to address sequential errors.

Assessing patient-centered communication in cancer care: stakeholder perspectives.

PURPOSE: Patient-centered communication is critical to quality cancer care. Effective communication can help patients and family members cope with cancer, make informed decisions, and effectively manage their care; suboptimal communication can contribute to care breakdowns and undermine clinician-patient relationships. The study purpose was to explore stakeholders' views on the feasibility and acceptability of collecting self-reported patient and family perceptions of communication experiences while receiving cancer care. The results were intended to inform the design, development, and implementation of a structured and generalizable patient-level reporting system. METHODS: This was a formative, qualitative study that used semistructured interviews with cancer patients, family members, clinicians, and leaders of health care organizations. The constant comparative method was used to identify major themes in the interview transcripts. RESULTS: A total of 106 stakeholders were interviewed. Thematic saturation was achieved. All stakeholders recognized the importance of communication and endorsed efforts to improve communication during cancer care. Patients, clinicians, and leaders expressed concerns about the potential consequences of reports of suboptimal communication experiences, such as damage to the clinician-patient relationship, and the need for effective improvement strategies. Patients and family members would report good communication experiences in order to encourage such practices. Practical and logistic issues were identified. CONCLUSION: Patient reports of their communication experiences during cancer care could increase understanding of the communication process, stimulate improvements, inform interventions, and provide a basis for evaluating changes in communication practices. This qualitative study provides a foundation for the design and pilot testing of such a patient reporting system.

Impact of electronic order management on the timeliness of antibiotic administration in critical care patients.

OBJECTIVE: To examine the effect of implementing electronic order management on the timely administration of antibiotics to critical-care patients. METHODS: We used a prospective pre-post design, collecting data on first-dose IV antibiotic orders before and after the implementation of an integrated electronic medication-management system, which included computerized provider order entry (CPOE), pharmacy order processing and an electronic medication administration record (eMAR). The research was performed in a 24-bed adult medical/surgical ICU in a large, rural, tertiary medical center. Data on the time of ordering, pharmacy processing and administration were prospectively collected and time intervals for each stage and the overall process were calculated. RESULTS: The overall turnaround time from ordering to administration significantly decreased from a median of 100 min before order management implementation to a median of 64 min after implementation. The first part of the medication use process, i.e., from order entry to pharmacy processing, improved significantly whereas no change was observed in the phase from pharmacy processing to medication administration. DISCUSSION: The implementation of an electronic order-management system improved the timeliness of antibiotic administration to critical-care patients. Additional system changes are required to further decrease the turnaround time.

Factors contributing to an increase in duplicate medication order errors after CPOE implementation.

OBJECTIVE: To evaluate the incidence of duplicate medication orders before and after computerized provider order entry (CPOE) with clinical decision support (CDS) implementation and identify contributing factors. DESIGN: CPOE with duplicate medication order alerts was implemented in a 400-bed Northeastern US community tertiary care teaching hospital. In a pre-implementation post-implementation design, trained nurses used chart review, computer-generated reports of medication orders, provider alerts, and staff reports to identify medication errors in two intensive care units (ICUs). MEASUREMENT: Medication error data were adjudicated by a physician and a human factors engineer for error stage and type. A qualitative analysis of duplicate medication ordering errors was performed to identify contributing factors. RESULTS: Data were collected for 4147 patient-days pre-implementation and 4013 patient-days post-implementation. Duplicate medication ordering errors increased after CPOE implementation (pre: 48 errors, 2.6% total; post: 167 errors, 8.1% total; p<0.0001). Most post-implementation duplicate orders were either for the identical order or the same medication. Contributing factors included: (1) provider ordering practices and computer availability, for example, two orders placed within minutes by different providers on rounds; (2) communication and hand-offs, for example, duplicate orders around shift change; (3) CDS and medication database design, for example confusing alert content, high false-positive alert rate, and CDS algorithms missing true duplicates; (4) CPOE data display, for example, difficulty reviewing existing orders; and (5) local CDS design, for example, medications in order sets defaulted as ordered. CONCLUSIONS: Duplicate medication order errors increased with CPOE and CDS implementation. Many work system factors, including the CPOE, CDS, and medication database design, contributed to their occurrence.

ICU nurses' acceptance of electronic health records.

OBJECTIVE: To assess intensive care unit (ICU) nurses' acceptance of electronic health records (EHR) technology and examine the relationship between EHR design, implementation factors, and nurse acceptance. DESIGN: The authors analyzed data from two cross-sectional survey questionnaires distributed to nurses working in four ICUs at a northeastern US regional medical center, 3 months and 12 months after EHR implementation. MEASUREMENTS: Survey items were drawn from established instruments used to measure EHR acceptance and usability, and the usefulness of three EHR functionalities, specifically computerized provider order entry (CPOE), the electronic medication administration record (eMAR), and a nursing documentation flowsheet. RESULTS: On average, ICU nurses were more accepting of the EHR at 12 months as compared to 3 months. They also perceived the EHR as being more usable and both CPOE and eMAR as being more useful. Multivariate hierarchical modeling indicated that EHR usability and CPOE usefulness predicted EHR acceptance at both 3 and 12 months. At 3 months postimplementation, eMAR usefulness predicted EHR acceptance, but its effect disappeared at 12 months. Nursing flowsheet usefulness predicted EHR acceptance but only at 12 months. CONCLUSION: As the push toward implementation of EHR technology continues, more hospitals will face issues related to acceptance of EHR technology by staff caring for critically ill patients. This research suggests that factors related to technology design have strong effects on acceptance, even 1 year following the EHR implementation.

Nontuberculous mycobacterial lung disease prevalence at four integrated health care delivery systems.

RATIONALE: Single-site clinic-based studies suggest an increasing prevalence of pulmonary nontuberculous mycobacteria (NTM) disease, but systematic data are lacking. OBJECTIVES: To describe prevalence and trends for NTM lung disease at four geographically diverse integrated heath care delivery systems in the United States. METHODS: We abstracted mycobacterial culture results from electronic laboratory databases and linked to other datasets containing clinical and demographic information. Possible cases were defined as a single positive NTM pulmonary isolate, and definite cases were defined as two positive sputum cultures, or one positive culture from a bronchoalveolar lavage or lung biopsy. Annual prevalence was calculated using United States census data; average annual prevalence is presented for 2004-2006. Poisson regression models were used to estimate the annual percent change in prevalence. MEASUREMENTS AND MAIN RESULTS: A total of 28,697 samples from 7,940 patients were included in the analysis. Of these, 3,988 (50%) were defined as possible cases, and 1,865 (47%) of these were defined as definite cases. Average annual (2004-2006) site-specific prevalence ranged from 1.4 to 6.6 per 100,000. Prevalence was 1.l- to 1.6-fold higher among women relative to men across sites. The prevalence of NTM lung disease was increasing significantly at the two sites where trends were studied, by 2.6% per year among women and 2.9% per year among men. Among persons aged greater than or equal to 60 years, annual prevalence increased from 19.6 per 100,000 during 1994-1996 to 26.7 per 100,000 during 2004-2006. CONCLUSIONS: The epidemiology of nontuberculous mycobacterial lung disease is changing, with a predominance of women and increasing prevalence at the sites studied.

Association of chromosome 9p21 SNPs with cardiovascular phenotypes in morbid obesity using electronic health record data.

Genomic medicine research requires substantial time and resources to obtain phenotype data. The electronic health record offers potential efficiencies in addressing these temporal and economic challenges, but few studies have explored the feasibility of using such data for genetics research. The main objective of this study was to determine the association of two genetic variants located on chromosome 9p21 conferring susceptibility to coronary heart disease and type 2 diabetes with a variety of clinical phenotypes derived from the electronic health record in a population of morbidly obese patients. Data on more than 100 clinical measures including diagnoses, laboratory values, and medications were extracted from the electronic health records of a total of 709 morbidly obese (body mass index (BMI) >/= 40 kg/m(2)) patients. Two common single nucleotide polymorphisms located at chromosome 9p21 recently linked to coronary heart disease and type 2 diabetes (McPherson et al. Science 316:1488-1491, 2007; Saxena et al. Science 316:1331-1336, 2007; Scott et al. Science 316:1341-1345, 2007) were genotyped to assess statistical association with clinical phenotypes. Neither the type 2 diabetes variant nor the coronary heart disease variant was related to any expected clinical phenotype, although high-risk type 2 diabetes/coronary heart disease compound genotypes were associated with several coronary heart disease phenotypes. Electronic health records may be efficient sources of data for validation studies of genetic associations.

Association of morbid obesity with FTO and INSIG2 allelic variants.

OBJECTIVE: To determine whether 2 single nucleotide polymorphisms (SNPs) in the obesity genes the fat mass and obesity associated gene (FTO) and the insulin induced gene 2 (INSIG2) are associated with class III, or morbid, obesity in patients undergoing bariatric weight loss operations. DESIGN: Retrospective analysis of genotype and clinical data. SETTING: Large rural tertiary care health system. PATIENTS: A total of 707 adult patients with a body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of at least 40 undergoing open or laparoscopic Roux-en-Y gastric bypass operations for morbid obesity or its comorbid medical problems at Geisinger Medical Center, Danville, Pennsylvania. RESULTS: The mean BMI in the predominantly white female cohort was 51.2. Approximately 21% of patients were homozygous for the FTO obesity SNP variant, 13% were homozygous for the INSIG2 obesity SNP variant, and 3.4% were homozygous for both. Mean BMIs in the groups homozygous for each of these genes were not significantly different from nonhomozygotes. However, FTO/INSIG2 double homozygotes and homozygote/heterozygote pairs had significantly higher BMIs than the other groups. CONCLUSION: Increased BMI in morbid obesity is associated with a combination of FTO and INSIG2 SNPs.