Specification of business rules for the development of hospital alarm system: application to the pharmaceutical validation.

Although clinical alarm systems are part of the knowledge management setting within healthcare organisations, modelling of business processes related to decision support and knowledge representation of decision rules are seldom described. We propose a customization of the Unified Process that takes into account user requirements for clinical alarm systems by introducing the Semantics of Business Vocabulary and Business Rules (SBVR). This methodology was applied to the design and implementation of a clinical alarm system for pharmaceutical validation at the European Hospital Georges Pompidou (HEGP). Rules were implemented using the IlogJRules Business Rule Management System. We produced 3 business rules patterns and 427 instances of rules. As SBVR is close to natural language, pharmacists were able to understand rules and participate to their design.

Evaluation of response to various erythropoiesis--stimulating proteins using anemia management software.

BACKGROUND: European Best Practice Guidelines recommend haemoglobin (Hb) concentration >11 g/dl in patients with CKD stage 5. Hb can be increased with erythropoiesis-stimulating proteins (ESPs); however, 5-10% of patients respond poorly. The primary aim of this prospective observational study was to educate nurses to assess Hb response to ESPs and to identify potential causes of hyporesponse (blood loss, iron deficiency, infection and inflammation, inefficacious dialysis, medication, vitamin deficiency, malnutrition, secondary hyperparathyroidism, or pure red cell aplasia). The secondary aims were to follow anaemia parameters and identify the frequency and causes of hyporesponse to ESPs for 6 months. Lastly, the various ESPs used in the study population were analyzed separately. METHODS: Dialysis patients (n=402) from 18 centers in Belgium and the Grand Duchy of Luxembourg were included. Using anaemia management software (ARAMIS), nurses recorded Hb, ESP dose, and potential causes for hyporesponse every 4 weeks. RESULTS: The proportion of patients treated with darbepoetin alpha, epoetin alpha, and epoetin beta was 64%, 19%, and 17%, respectively. After 6 months, 79% of patients had Hb >11 g/dl. The patient incidence of hyporesponse during the study was 14%, and a mean 9% of patients were hyporesponsive at any given time. The most common potential causes of hyporesponse were iron deficiency (being reported in 39% of hyporesponse events), medication (immunosuppressive agents, ACE inhibitors), secondary hyperparathyroidism and inflammation/malnutrition. CONCLUSIONS: The ARAMIS tool served as an educational tool allowing efficient follow-up of Hb and ESP dose, and identification of potential causes of hyporesponse. Mean prevalence of hyporesponse was 9%, with iron deficiency as most commonly reported potential causative factor.

Technology into practice: young people's, parents' and nurses' perceptions of WISECARE+.

UNLABELLED: Technology is a central aspect of young people's lives, with the internet and mobile phone technology providing the preferred means of communication. This pilot explored perceptions and experiences of young people, parents and healthcare professionals on the role of technology in monitoring and managing chemotherapy-related toxicity. AIM: To introduce the WISECARE+ process for recording and communicating symptoms following chemotherapy to a teenage patient population and evaluate its usefulness with patients, parents and nursing staff. METHOD: A convenience sample of 11 young people (aged 13 to 20 years) with a haematological or solid tumour undergoing primary treatment, were recruited from two UK regional paediatric oncology centres. The young people completed a daily symptom questionnaire for 14 consecutive days following a course of chemotherapy. They evaluated the presence or absence of symptoms of nausea, vomiting, fatigue and oral problems, their severity and how much the symptom bothered them. Perception questionnaires were completed by the 11 young people, four parents and eight nurses at the end of the 14 days. RESULTS: Young people and parents found the symptom questionnaire simple to understand, easy to complete and they liked the paper format. The nurses' confidence with IT varied but all felt that it could be useful in their clinical practice. CONCLUSION: These young people appeared to gain from their participation in the project, especially in relation to completing the questionnaire as they were able to see a change in symptoms over time that was encouraging, particularly in situations where the young person had been quite ill. This work is continuing with formats such as a handheld computer or mobile phone being considered to collect symptom information. Additional factors such as reading levels and dyslexia are also being considered.

Test the artefact--develop the organization. The implementation of an electronic medication plan.

OBJECTIVE AND METHODS: The paper aims to develop further insights into the process of implementation of IT in health care by describing findings from a study of a trial implementation of a newly developed electronic medication plan (EMP) in three hospitals in a county in Denmark. A sociotechnical perspective is applied to data acquired by the qualitative methods of participant observation and semi-structured open-ended interviews. CONCLUSIONS: The achievement of fit between IT technology and work processes in health care involves the establishment of new organizational structures that cut across the existing divisionalized hospital organization and a detailed alignment of artefact, functionality and work process. This process can be furthered by supporting 'communities of practice', i.e. informal groups of engaged clinicians. A sociotechnical perspective is beneficial to the analysis of such processes.

The need for organizational change in patient safety initiatives.

OBJECTIVES: This study describes a computer simulation model that has been developed to explore organizational changes required to improve patient safety based on a medication error reporting system. METHODS: Model parameters for the simulation model were estimated from data submitted to the MEDMARX medication error reporting system from 570 healthcare facilities in the U.S. The model's results were validated with data from the Pittsburgh Regional Healthcare Initiative consisting of 44 hospitals in Pennsylvania that have adopted the MEDMARX medication error reporting system. The model was used to examine the effects of organizational changes in response to the error reporting system. Four interventions were simulated involving the implementation of computerized physician order entry, decision support systems and a clinical pharmacist on hospital rounds. CONCLUSIONS: Results of the analysis indicate that improved patient safety requires more than clinical initiatives and voluntary reporting of errors. Organizational change is essential for significant improvements in patient safety. In order to be successful, these initiatives must be designed and implemented through organizational support structures and institutionalized through enhanced education, training, and implementation of information technology that improves work flow capabilities.

Error reduction in pediatric chemotherapy: computerized order entry and failure modes and effects analysis.

OBJECTIVE: To implement and evaluate the impact of computerized provider order entry (CPOE) on reducing ordering errors in pediatric chemotherapy. DESIGN: Before-and-after study from 2001 to 2004. SETTING: Pediatric Oncology in an academic medical center. INTERVENTION: Implementation of a CPOE system guided by multidisciplinary failure modes and effects analysis into pediatric chemotherapy. MAIN OUTCOME MEASURES: Completion data on chemotherapy steps of high morbidity/mortality potential if missed (as determined by attending oncologists) from 1259 pre-CPOE paper and 1116 post-CPOE pediatric chemotherapy orders. RESULTS: After CPOE deployment, daily chemotherapy orders were less likely to have improper dosing (relative risk [RR], 0.26; 95% confidence interval [CI], 0.11-0.61), incorrect dosing calculations (RR, 0.09; 95% CI, 0.03-0.34), missing cumulative dose calculations (RR, 0.32; 95% CI, 0.14-0.77), and incomplete nursing checklists (RR, 0.51; 95% CI, 0.33-0.80). There was no difference in the likelihood of improper dosing on treatment plans and a higher likelihood of not matching medication orders to treatment plans (RR, 5.4; 95% CI, 3.1-9.5). CONCLUSION: Failure modes and effects analysis-guided CPOE reduced ordering errors in pediatric chemotherapy and provided data for further improvements.

The FDA announces new prescription drug information format.

In January 2006, the Food and Drug Administration unveiled a major revision to the format of prescription drug information, commonly called the package insert. To manage the risks of medication use and to reduce medical errors, the newly designed package insert will provide the most up-to-date information in an easy-to-read format that draws physician and patient attention to the most important pieces of drug information before a product is prescribed. The new format also will make prescription information more accessible for use with electronic prescribing tools and other electronic information resources.

[Implementation of an assisted electronic prescription system applied to parenteral nutrition in a general hospital]. / Implantación de un sistema de prescripción electrónica asistida aplicada a la nutrición parenteral en un hospital general.

Integrated and shared information systems allow obtaining a high degree of information about processes, costs and outcomes, and considerably reducing prescription errors. Assisted electronic prescription, in the setting of total parenteral nutrition, integrated with other hospital databases and with the hospital drugs management system, is a tool that allows increasing patient' safety (by reducing prescription errors), improving quality assistance, improving information systems and information management and the efficiency of used resources. In this work, implementation of an assisted electronic prescription system applied to parenteral nutrition in a hospital and processes reengineering performed in the nutrition setting are described. This implementation was performed by medical staff from the Nutrition and Diet Department and pharmacists from the Pharmacy Department of Ramón y Cajal Hospital using "Nutriwin" computer software. For two months prior and after its implementation, a follow-up of time consumed in the circuit prescription-validation-elaboration-dispensation of parenteral nutrition formulas has been performed. After implementation, treatment orders reach on average 1 h and 15 minutes sooner the Pharmacy Department; by avoiding transcription, a saving of 3 min per nutrition formula calculations is achieved, besides reducing potential errors; elaboration of nutrition formulas can be started on average 1 h and 20 minutes sooner as compared to manual prescription. Besides, the staff that writes down the prescription may know in real time the nutritional profile for each patient in the current episode and the patient's historic. Electronic prescription of treatment orders in this area has represented for our hospital an optimization of the employed resources, a reduction of potential errors that may occur, an improvement in consumption management, and an increase in the whole process quality.

[Frequency, relevance, causes of and strategies for prevention of medication errors]. / Häufigkeit, Relevanz, Ursachen und Strategien zur Vermeidung von Medikationsfehlern.

Drug therapy has led to major advances in medicine. The beneficial effects of drug therapy are coupled with the inevitable risk of adverse drug reactions especially in elderly patients. Many adverse drug reactions are preventable. The electronic health card that will be introduced in Germany starting in 2006 is designed to support electronic decision support to prevent medication errors. Studies have demonstrated that CPOES can reduce medication errors by 80%. The necessary steps to improve medication safety in Germany are outlined and discussed.

Computer-supported weight-based drug infusion concentrations in the neonatal intensive care unit.

This article addresses the development of a computerized provider order entry (CPOE)-embedded solution for weight-based neonatal drug infusion developed during the transition from a legacy CPOE system to a customized application of a neonatal CPOE product during a hospital-wide information system transition. The importance of accurate fluid management in the neonate is reviewed. The process of tailoring the system that eventually resulted in the successful development of a computer application enabling weight-based medication infusion calculation for neonates within the CPOE information system is explored. In addition, the article provides guidelines on how to customize a vendor solution for hospitals with neonatal intensive care unit.

An intravenous medication safety system: preventing high-risk medication errors at the point of care.

Improving medication safety at the point of care--particularly for high-risk drugs--is a major concern of nursing administrators. The medication errors most likely to cause harm are administration errors related to infusion of high-risk medications. An intravenous medication safety system is designed to prevent high-risk infusion medication errors and to capture continuous quality improvement data for best practice improvement. Initial testing with 50 systems in 2 units at Vanderbilt University Medical Center revealed that, even in the presence of a fully mature computerized prescriber order-entry system, the new safety system averted 99 potential infusion errors in 8 months.

Bridging the gap: the Virtual Chemotherapy Unit.

Due to the complexity of pediatric chemotherapy administration, systems promoting safety must be utilized. Computerized order entry has been proven to reduce errors in the ordering of chemotherapeutic agents. A task force (the Breakthrough Committee) at The Children's Hospital of Philadelphia (CHOP) evaluated systems and identified the need to streamline the chemotherapy admission process from the outpatient clinic to the inpatient unit. In the outpatient setting chemotherapy orders were handwritten, whereas inpatient orders were computerized. Patients due for chemotherapy admissions were unable to start chemotherapy until they were physically admitted to an inpatient bed. In many cases, patients would not start receiving chemotherapy until late in the evening or even overnight. The Breakthrough Committee created the Virtual Chemotherapy Unit (Virtual Unit), which standardizes the ordering and documentation for all chemotherapy admissions. As per its name, the Virtual Unit is not an actual hospital unit but merely a location in the computer system where the patient is admitted prior to having a bed on the inpatient unit. Patients are now able to start chemotherapy infusions in the outpatient setting early in the day, rather than waiting until arrival to the inpatient unit. The nurses in the outpatient clinic are able to document chemotherapy administration online, giving the inpatient staff the ability to view the medications that were given. The Virtual Unit bridges the gap in chemotherapy ordering and documentation by utilizing 1 online episode per patient admission. Oncology nurses at CHOP played a fundamental role in the creation of the Virtual Unit. Nurses identified situations with potential for error in the ordering and administration of chemotherapy. These scenarios were analyzed and used in creating a safer system.

Computer-based drug management in a bone marrow transplant unit: a suitable tool for multiple prescriptions even in critical conditions.

Drug prescription or administration errors are the most common causes of adverse events for hospital patients. Computer-based systems can be effective in reducing these errors. The aim of this study was to assess whether computer-based systems are easily exploitable even in critical conditions. The oral and handwritten system for drug management was completely replaced by a computer-based system in our bone marrow transplant unit, chosen because: (i) the intensive treatments could test the efficiency of the system; (ii) the very frequent occurrence of complications and emergencies could test the flexibility of the system; and (iii) the pre-existing system could be used as comparison. From May to November 2002, 41 patients were repeatedly admitted to undergo high-dose chemotherapy, autologous/allogeneic stem cell transplantation or because of severe complications. In 27 consecutive admissions, 2264 drug prescriptions (average, 29 drugs/patient admission) and 36 786 drug administrations (39.8/patient/d) were carried out. Despite the large number of procedures, the computerized system effectively replaced the oral and handwritten transmission of information among medical staff, pharmacists and nurses, and lowered the error risks. In addition, it contributed to medical updating through warnings on potential problems in case of multiple drug prescriptions, and gave the pharmacy a valuable tool to monitor drug use.

A conceptual framework for evaluating outpatient electronic prescribing systems based on their functional capabilities.

OBJECTIVE: Electronic prescribing (e-prescribing) may substantially improve health care quality and efficiency, but the available systems are complex and their heterogeneity makes comparing and evaluating them a challenge. The authors aimed to develop a conceptual framework for anticipating the effects of alternative designs for outpatient e-prescribing systems. DESIGN: Based on a literature review and on telephone interviews with e-prescribing vendors, the authors identified distinct e-prescribing functional capabilities and developed a conceptual framework for evaluating e-prescribing systems' potential effects based on their capabilities. Analyses of two commercial e-prescribing systems are presented as examples of applying the conceptual framework. MEASUREMENTS: Major e-prescribing functional capabilities identified and the availability of evidence to support their specific effects. RESULTS: The proposed framework for evaluating e-prescribing systems is organized using a process model of medication management. Fourteen e-prescribing functional capabilities are identified within the model. Evidence is identified to support eight specific effects for six of the functional capabilities. The evidence also shows that a functional capability with generally positive effects can be implemented in a way that creates unintended hazards. Applying the framework involves identifying an e-prescribing system's functional capabilities within the process model and then assessing the effects that could be expected from each capability in the proposed clinical environment. CONCLUSION: The proposed conceptual framework supports the integration of available evidence in considering the full range of effects from e-prescribing design alternatives. More research is needed into the effects of specific e-prescribing functional alternatives. Until more is known, e-prescribing initiatives should include provisions to monitor for unintended hazards.

Reporting medication errors through computerized medication administration.

The incidence of medication errors has risen dramatically during the last decade to an alarming number. Nurses report only 5% of significant errors, those considered life threatening. Little research has been done related to medication errors at the administration stage or reporting methods. The purpose of this study was to compare medication error rate per 1,000 doses administered before and after the implementation of a bar code medication administration system. The study was conducted on two medical-surgical units at a midwest government hospital 12 months both before and after the implementation of the Bar Code Medication Administration system. The medication error rate per 1,000 doses administered by a nurse after implementation of the Bar Code Medication Administration system showed an 18% increase. The results probably do not indicate an increase in medication errors but rather an increase in the number of medication errors reported. This research highlights problems with programs evaluating medication errors and new technology implementation. Evaluators must have accurate baseline data before implementation. Past research has shown that the medication error rate has been underreported. In contrast to a staff reporting system, the computerization of medication administration improves the reporting system by reporting all errors. Once a more accurate error rate is known, new technology can be created, evaluated, and refined to reduce medication errors.