Mixed results in the safety performance of computerized physician order entry.

Computerized physician order entry is a required feature for hospitals seeking to demonstrate meaningful use of electronic medical record systems and qualify for federal financial incentives. A national sample of sixty-two hospitals voluntarily used a simulation tool designed to assess how well safety decision support worked when applied to medication orders in computerized order entry. The simulation detected only 53 percent of the medication orders that would have resulted in fatalities and 10-82 percent of the test orders that would have caused serious adverse drug events. It is important to ascertain whether actual implementations of computerized physician order entry are achieving goals such as improved patient safety.

Lessons learned from a nightclub fire: institutional disaster preparedness.

BACKGROUND: On February 20, 2003, a nightclub fire caused a multiple casualty disaster, with 215 victims requiring treatment at area hospitals. In this report, we describe the events, the surgical response at our trauma center, and the lessons learned in institutional disaster preparedness. METHODS: Information regarding the fire was obtained from public access media and state governmental and hospital reports. Patient information was obtained through review of our trauma registry, patient records, and questionnaires sent to regional hospitals. RESULTS: Four hundred thirty-nine patrons were in the building at the time of the fire, of whom 96 died at the scene. One hundred people ultimately died. Two hundred fifteen patients were evaluated at area hospitals: 64 at our trauma center and 151 at 15 other area facilities. Seventy-nine patients were admitted: 47 to our center and 32 to other hospitals. Eight patients were transferred from Rhode Island Hospital (RIH) to other Level I trauma centers. Twenty-eight (60%) of the patients admitted to RIH were intubated for inhalation injury. For patients admitted to RIH, the extent of the total body surface burn was less than 20% in 33 patients (70%), 21% to 40% in 12 patients (26%), and greater than 40% in 2 patients (4%). The average age was 31 years (range, 18-43 years). Previous disaster planning drills facilitated a quick institutional response directed by a surgeon. The trauma floor of the hospital, which normally consists of a 10-bed trauma intensive care unit (ICU), an 11-bed step-down unit, and a 22-bed medical-surgical floor, was cleared of patients and converted into a 21-bed burn ICU and a 34-bed acute burn ward. Surgical residents were mobilized into teams assigned to the emergency department, ICUs, and surgical floors. In addition to the in-house trauma attending already present, four additional surgical staff members were called in to help man the emergency department and burn wards. Two operating rooms became dedicated burn rooms where 23 cases were performed the first week. In total, 43 operative procedures and 9 bedside tracheostomies were performed over 8 weeks. Over the first 4 weeks, 132 bronchoscopies were performed for diagnostic purposes and pulmonary toilet. There were no deaths. CONCLUSION: Disaster planning as well as personnel and institutional commitment resulted in an optimal response to a multiple casualty incident. Still, lessons were learned that will further improve readiness for future disasters.

Improving medication safety: the measurement conundrum and where to start.

The use of medication remains the most common intervention in health care. The complexity of both medication use and the medication management process, especially in the in-patient setting, create a significant risk for hospitalized patients. Despite the widespread recognition of the hazards that medication use poses to patients, there are no widely accepted or standardized methods to measure the safety of medication use. Where to focus measurement in medication safety is the subject of ongoing debate. Various groups have suggested measuring error-prone aspects of the medication use process such as errors in administration of medications or errors in dispensing of medications. Other groups have suggested measuring adverse drug events as a measure of the safety of medication use. Many studies in this area have outlined the great difficulty associated with getting clinicians to report either medication errors or adverse drug events voluntarily. In response to these challenges, yet more groups have developed non-voluntary reporting methods based on the use of "triggers", in either a chart review or electronic format. Medication safety is a complex process and measurement of it needs to be a core component throughout the whole process. With the introduction of computerized analysis of patient information, measurement becomes much easier and potentially more powerful and achievable than either incident reporting or chart reviews for purposes of accountability, prevention, and ongoing improvement of both process and clinical practice. This paper reviews approaches to measuring medication safety from the perspective of both harm and error, and outlines a strategy that combines both approaches in the electronic era.

Understanding hospital readiness for computerized physician order entry.

BACKGROUND: Many hospitals in the United States are in early stages of decision making and planning to implement computerized physician order entry (CPOE) to improve patient safety and quality of care. The targeted processes and the software for CPOE are complex, and implementation is a large-scale change effort for most hospitals. Hospitals can increase the likelihood of success by understanding and addressing gaps in CPOE readiness. ASSESSING CPOE READINESS: A CPOE readiness assessment tool was developed that includes several different components: external environment; organizational leadership, structure, and culture; care standardization;, order management; access to information; information technology composition; and infrastructure. The presence or absence of these indicators in a particular hospital was determined by on-site interviews, walkarounds with direct observations, and document review. RESULTS: Assessment results for the first 17 hospitals (bed size, 75-906 beds) indicated that the lowest average component score was in care standardization, while the highest average component score was in organizational structure and function. Organizational culture and the order management process also had low average scores. CONCLUSIONS: This CPOE readiness assessment revealed significant gaps in all the hospitals examined. Identifying these gaps and addressing them before CPOE implementation can reduce risks. Organizations need to develop expertise at accomplishing and sustaining change; understanding and building CPOE readiness is an important first step.