A computer alert system to prevent injury from adverse drug events: development and evaluation in a community teaching hospital.

CONTEXT: Adverse drug events (ADEs) are the most common type of iatrogenic injury occurring in hospitalized patients. Errors leading to ADEs are often due to restricted availability of information at the time of physician order writing. OBJECTIVES: To develop, implement, and evaluate a computer alert system designed to correct errors that might lead to ADEs and to detect ADEs before maximum injury occurs. DESIGN: Prospective case series. SETTING: A 650-bed community teaching hospital in Phoenix, Ariz. PATIENTS: Consecutive sample of 9306 nonobstetrical adult patients admitted during the last 6 months of 1997. INTERVENTIONS: Thirty-seven drug-specific ADEs were targeted. Our hospital information system was programmed to generate alerts in clinical situations with increased risk for ADE-related injury. A clinical system was developed to ensure physician notification of alerts. MAIN OUTCOME MEASURES: A true-positive alert was defined as one in which the physician wrote orders consistent with the alert recommendation after alert notification. RESULTS: During the 6-month study period, the alert system fired 1116 times and 596 were true-positive alerts (positive predictive value of 53%). The alerts identified opportunities to prevent patient injury secondary to ADEs at a rate of 64 per 1000 admissions. A total of 265 (44%) of the 596 true-positive alerts were unrecognized by the physician prior to alert notification. CONCLUSIONS: Clinicians can use hospital information systems to detect opportunities to prevent patient injury secondary to a broad range of ADEs.

The effectiveness of implementing the weight-based heparin nomogram as a practice guideline.

OBJECTIVE: To determine the effectiveness of the nomogram in a community hospital that implemented it as a practice guideline. DESIGN: A nonexperimental, retrospective time series. SETTING: A 600-bed community teaching hospital and regional referral center in Phoenix, Ariz. PATIENTS: The study population included 591 consecutive patients with venous thromboembolism, treated over a 5-year study period. METHODS: During this period, the weight-based heparin nomogram was adapted into a preprinted order sheet and distributed to the hospital wards. The main outcome variables were the time to achieve a therapeutic activated partial thromboplastin time and the rate of bleeding complications. RESULTS: Voluntary implementation of the nomogram steadily increased, reaching 94%. Comparison of the periods before and after 50% implementation demonstrated an increase in initial heparin dose (1185 vs 1420 U/h, P < .001), a decrease in time to achieve therapeutic activated partial thromboplastin time (19.6 vs 11.8 hours), a decrease in the variance of this parameter (25 vs 4 hours, P < .001), and no change in bleeding rates. The proportion of patients achieving a therapeutic activated partial thromboplastin time within 24 hours decreased from 97% to 86% when the results from our previous randomized controlled trial (efficacy) are compared with the present results (effectiveness). CONCLUSIONS: The weight-based heparin nomogram was well accepted by clinicians at our institution and led to more aggressive heparin dosing and improvements in intermediate outcomes, without increasing bleeding. Mitigation of benefit is likely to occur when practice guidelines are moved from the realm of efficacy research into clinical practice. Therefore, the effectiveness of such measures requires monitoring.