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Appl Clin Inform 2020; 11(02): 323-335
DOI: 10.1055/s-0040-1709508
Research Article
Georg Thieme Verlag KG Stuttgart · New York

The Impact of Technology on Prescribing Errors in Pediatric Intensive Care: A Before and After Study

Moninne M. Howlett
1   Department of Pharmacy, Children's Health Ireland at Crumlin, Dublin, Ireland
2   School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland
3   National Children's Research Centre, Crumlin, Dublin, Ireland
,
Eileen Butler
1   Department of Pharmacy, Children's Health Ireland at Crumlin, Dublin, Ireland
,
Karen M. Lavelle
1   Department of Pharmacy, Children's Health Ireland at Crumlin, Dublin, Ireland
,
Brian J. Cleary
2   School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland
4   Department of Pharmacy, The Rotunda Hospital, Parnell Square, Dublin, Ireland
,
Cormac V. Breatnach
1   Department of Pharmacy, Children's Health Ireland at Crumlin, Dublin, Ireland
› Institutsangaben Funding This study received its funding from National Children's Research Centre (D/14/1).
Weitere Informationen

Publikationsverlauf

17. Dezember 2019

27. Februar 2020

Publikationsdatum:
06. Mai 2020 (online)

   Lizenzen und Reprints

Abstract

Background Increased use of health information technology (HIT) has been advocated as a medication error reduction strategy. Evidence of its benefits in the pediatric setting remains limited. In 2012, electronic prescribing (ICCA, Philips, United Kingdom) and standard concentration infusions (SCIs)—facilitated by smart-pump technology—were introduced into the pediatric intensive care unit (PICU) of an Irish tertiary-care pediatric hospital.

Objective The aim of this study is to assess the impact of the new technology on the rate and severity of PICU prescribing errors and identify technology-generated errors.

Methods A retrospective, before and after study design, was employed. Medication orders were reviewed over 24 weeks distributed across four time periods: preimplementation (Epoch 1); postimplementation of SCIs (Epoch 2); immediate postimplementation of electronic prescribing (Epoch 3); and 1 year postimplementation (Epoch 4). Only orders reviewed by a clinical pharmacist were included. Prespecified definitions, multidisciplinary consensus and validated grading methods were utilized.

Results A total of 3,356 medication orders for 288 patients were included. Overall error rates were similar in Epoch 1 and 4 (10.2 vs. 9.8%; p = 0.8), but error types differed (p < 0.001). Incomplete and wrong unit errors were eradicated; duplicate orders increased. Dosing errors remained most common. A total of 27% of postimplementation errors were technology-generated. Implementation of SCIs alone was associated with significant reductions in infusion-related prescribing errors (29.0% [Epoch 1] to 14.6% [Epoch 2]; p < 0.001). Further reductions (8.4% [Epoch 4]) were identified after implementation of electronically generated infusion orders. Non-infusion error severity was unchanged (p = 0.13); fewer infusion errors reached the patient (p < 0.01). No errors causing harm were identified.

Conclusion The limitations of electronic prescribing in reducing overall prescribing errors in PICU have been demonstrated. The replacement of weight-based infusions with SCIs was associated with significant reductions in infusion prescribing errors. Technology-generated errors were common, highlighting the need for on-going research on HIT implementation in pediatric settings.

Keywords

clinical information systems - intensive and critical care - pediatrics - computer-assisted decision-making - medical order entry systems - prescriptions - medication errors - infusion pumps

Protection of Human and Animal Subjects

No human/animal subjects were involved in this study.


 

  • References

  • 1 Steering Committee on Quality Improvement and Management and Committee on Hospital Care. Policy statement--principles of pediatric patient safety: reducing harm due to medical care. Pediatrics 2011; 127 (06) 1199-1210
    CrossrefPubMedGoogle Scholar
  • 2 Manias E, Kinney S, Cranswick N, Williams A, Borrott N. Interventions to reduce medication errors in pediatric intensive care. Ann Pharmacother 2014; 48 (10) 1313-1331
    CrossrefPubMedGoogle Scholar
  • 3 Dufendach KR, Eichenberger JA, McPheeters ML. , et al. Core Functionality in Pediatric Electronic Health Records. Rockville, MD: Agency for Healthcare Research and Quality (US); 2015
    Google Scholar
  • 4 Prgomet M, Li L, Niazkhani Z, Georgiou A, Westbrook JI. Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: a systematic review and meta-analysis. J Am Med Inform Assoc 2017; 24 (02) 413-422
    CrossrefPubMedGoogle Scholar
  • 5 Gates PJ, Meyerson SA, Baysari MT, Westbrook JI. The prevalence of dose errors among pediatric patients in hospital wards with and without health information technology: a systematic review and meta-analysis. Drug Saf 2019; 42 (01) 13-25
    CrossrefPubMedGoogle Scholar
  • 6 Potts AL, Barr FE, Gregory DF, Wright L, Patel NR. Computerized physician order entry and medication errors in a pediatric critical care unit. Pediatrics 2004; 113 (1 Pt 1): 59-63
    CrossrefPubMedGoogle Scholar
  • 7 Warrick C, Naik H, Avis S, Fletcher P, Franklin BD, Inwald D. A clinical information system reduces medication errors in pediatric intensive care. Intensive Care Med 2011; 37 (04) 691-694
    CrossrefPubMedGoogle Scholar
  • 8 Manrique-Rodríguez S, Sánchez-Galindo AC, Fernández-Llamazares CM, Calvo-Calvo MM, Carrillo-Álvarez Á, Sanjurjo-Sáez M. Safe intravenous administration in pediatrics: A 5-year pediatric intensive care unit experience with smart pumps. Med Intensiva 2016; 40 (07) 411-421
    CrossrefPubMedGoogle Scholar
  • 9 Rich DS. New JCAHO medication management standards for 2004. Am J Health Syst Pharm 2004; 61 (13) 1349-1358
    CrossrefPubMedGoogle Scholar
  • 10 Institute for Safe Medication Practices, Vermont Oxford Network. Standard concentrations of neonatal drug infusions 2011. Available at: https://www.ismp.org/recommendations/standard-concentrations-neonatal-drug-infusions . Accessed November 25, 2019
    PubMedGoogle Scholar
  • 11 Institute for Safe Medication Practices. ISMP. 2018–2019 Targeted medication safety best practices for hospitals. Available at: https://www.ismp.org/sites/default/files/attachments/2019-01/TMSBP-for-Hospitalsv2.pdf . Accessed November 25, 2019
    PubMedGoogle Scholar
  • 12 American Society of Health-System Pharmacists. ASHP. Standardize 4 safety. Available at: https://www.ashp.org/pharmacy-practice/standardize-4-safety-initiative . Accessed November 25, 2019
    PubMedGoogle Scholar
  • 13 The making it safer together (MiST) pediatric patient safety collaborative. Available at: http://www.mist-collaborative.net/ . Accessed January 25, 2020
    PubMedGoogle Scholar
  • 14 Howlett M, Curtin M, Doherty D, Gleeson P, Sheerin M, Breatnach C. Pediatric standardised concentration infusions - a national solution. Arch Dis Child 2016; 101 (09) e2
    PubMedGoogle Scholar
  • 15 Oskarsdottir T, Harris D, Sutherland A, Wignell A, Christiansen N. A national scoping survey of standard infusions in pediatric and neonatal intensive care units in the United Kingdom. J Pharm Pharmacol 2018; 70 (10) 1324-1331
    CrossrefPubMedGoogle Scholar
  • 16 Lyons I, Furniss D, Blandford A. , et al. Errors and discrepancies in the administration of intravenous infusions: a mixed methods multihospital observational study. BMJ Qual Saf 2018; 27 (11) 892-901
    CrossrefPubMedGoogle Scholar
  • 17 Parshuram CS, Ng GY, Ho TK. , et al. Discrepancies between ordered and delivered concentrations of opiate infusions in critical care. Crit Care Med 2003; 31 (10) 2483-2487
    CrossrefPubMedGoogle Scholar
  • 18 McLeroy PA. The rule of six: calculating intravenous infusions in a pediatric crisis situation. Hosp Pharm 1994; 29 (10) 939-940
    PubMedGoogle Scholar
  • 19 Lehmann CU, Kim GR, Gujral R, Veltri MA, Clark JS, Miller MR. Decreasing errors in pediatric continuous intravenous infusions. Pediatr Crit Care Med 2006; 7 (03) 225-230
    CrossrefPubMedGoogle Scholar
  • 20 Korb-Savoldelli V, Boussadi A, Durieux P, Sabatier B. Prevalence of computerized physician order entry systems-related medication prescription errors: a systematic review. Int J Med Inform 2018; 111: 112-122
    CrossrefPubMedGoogle Scholar
  • 21 U.S. Food and Drug Administration Office of Surveillance and Epidemiology - Centre for Drug Evaluation and Research. Computerized Prescriber Order Entry Medication Safety (CPOEMS): uncovering and learning from issues and errors. Secondary Computerized Prescriber Order Entry Medication Safety (CPOEMS): Uncovering and learning from issues and errors. Available at: http://www.fda.gov/downloads/Drugs/DrugSafety/MedicationErrors/UCM477419.pdf . Accessed January 25, 2020
    PubMedGoogle Scholar
  • 22 Westbrook JI, Baysari MT, Li L, Burke R, Richardson KL, Day RO. The safety of electronic prescribing: manifestations, mechanisms, and rates of system-related errors associated with two commercial systems in hospitals. J Am Med Inform Assoc 2013; 20 (06) 1159-1167
    CrossrefPubMedGoogle Scholar
  • 23 Lisby M, Nielsen LP, Brock B, Mainz J. How are medication errors defined? A systematic literature review of definitions and characteristics. Int J Qual Health Care 2010; 22 (06) 507-518
    CrossrefPubMedGoogle Scholar
  • 24 Philips Critical Care and Anesthesia. Available at: https://www.philips.ie/healthcare/product/HCNOCTN332/intellispace-critical-care-and-anesthesia . Accessed January 20, 2020
    PubMed
  • 25 Butler E, Howlett MM. Building a drug file for a clinical information management system: grand designs or room to improve?. Arch Dis Child 2013; 98 (06) e1
    PubMedGoogle Scholar
  • 26 Kaushal R, Bates DW, Landrigan C. , et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001; 285 (16) 2114-2120
    CrossrefPubMedGoogle Scholar
  • 27 Slater A, Shann F, Pearson G. ; Pediatric Index of Mortality (PIM) Study Group. PIM2: a revised version of the Pediatric Index of Mortality. Intensive Care Med 2003; 29 (02) 278-285
    CrossrefPubMedGoogle Scholar
  • 28 Howlett MM, Cleary BJ, Breatnach CV. Defining electronic-prescribing and infusion-related medication errors in pediatric intensive care - a Delphi study. BMC Med Inform Decis Mak 2018; 18 (01) 130
    CrossrefPubMedGoogle Scholar
  • 29 Ghaleb MA, Barber N, Dean Franklin B, Wong ICK. What constitutes a prescribing error in pediatrics?. Qual Saf Health Care 2005; 14 (05) 352-357
    CrossrefPubMedGoogle Scholar
  • 30 National Coordinating Council for Medication Error Reporting and Prevention. NCCMERP. NCC MERP index for categorizing medication errors. Available at: http://www.nccmerp.org/sites/default/files/algorColor2001-06-12.pdf . Accessed January 25, 2020
    PubMedGoogle Scholar
  • 31 Dean BS, Barber ND. A validated, reliable method of scoring the severity of medication errors. Am J Health Syst Pharm 1999; 56 (01) 57-62
    CrossrefPubMedGoogle Scholar
  • 32 Ghaleb MA, Barber N, Franklin BD, Wong ICK. The incidence and nature of prescribing and medication administration errors in pediatric inpatients. Arch Dis Child 2010; 95 (02) 113-118
    CrossrefPubMedGoogle Scholar
  • 33 Cimino MA, Kirschbaum MS, Brodsky L, Shaha SH. ; Child Health Accountability Initiative. Assessing medication prescribing errors in pediatric intensive care units. Pediatr Crit Care Med 2004; 5 (02) 124-132
    CrossrefPubMedGoogle Scholar
  • 34 Rinke ML, Bundy DG, Velasquez CA. , et al. Interventions to reduce pediatric medication errors: a systematic review. Pediatrics 2014; 134 (02) 338-360
    CrossrefPubMedGoogle Scholar
  • 35 Meyer-Massetti C, Cheng CM, Schwappach DL. , et al. Systematic review of medication safety assessment methods. Am J Health Syst Pharm 2011; 68 (03) 227-240
    CrossrefPubMedGoogle Scholar
  • 36 Kadmon G, Pinchover M, Weissbach A, Kogan Hazan S, Nahum E. Case Not closed: prescription errors 12 years after computerized physician order entry implementation. J Pediatr 2017; 190: 236-240.e2
    CrossrefPubMedGoogle Scholar
  • 37 Kadmon G, Bron-Harlev E, Nahum E, Schiller O, Haski G, Shonfeld T. Computerized order entry with limited decision support to prevent prescription errors in a PICU. Pediatrics 2009; 124 (03) 935-940
    CrossrefPubMedGoogle Scholar
  • 38 Hilmas E, Sowan A, Gaffoor M, Vaidya V. Implementation and evaluation of a comprehensive system to deliver pediatric continuous infusion medications with standardized concentrations. Am J Health Syst Pharm 2010; 67 (01) 58-69
    CrossrefPubMedGoogle Scholar
  • 39 Vaidya V, Sowan AK, Mills ME, Soeken K, Gaffoor M, Hilmas E. Evaluating the safety and efficiency of a CPOE system for continuous medication infusions in a pediatric ICU. AMIA Symposium 2006:1128. Available at: https://www.ncbi.nlm.nih.gov/pubmed/17238747 . Accessed March 13, 2020
    PubMedGoogle Scholar
  • 40 National Quality Forum. Identification and prioritization of health IT patient safety measures - final report secondary identification and prioritization of health IT patient safety measures - final report 2016. Available at: https://psnet.ahrq.gov/resources/resource/29853 . Accessed January 25, 2020
    PubMedGoogle Scholar
  • 41 Walsh KE, Landrigan CP, Adams WG. , et al. Effect of computer order entry on prevention of serious medication errors in hospitalized children. Pediatrics 2008; 121 (03) e421-e427
    CrossrefPubMedGoogle Scholar
  • 42 Amato MG, Salazar A, Hickman TT. , et al. Computerized prescriber order entry-related patient safety reports: analysis of 2522 medication errors. J Am Med Inform Assoc 2017; 24 (02) 316-322
    CrossrefPubMedGoogle Scholar
  • 43 Wetterneck TB, Walker JM, Blosky MA. , et al. Factors contributing to an increase in duplicate medication order errors after CPOE implementation. J Am Med Inform Assoc 2011; 18 (06) 774-782
    CrossrefPubMedGoogle Scholar
  • 44 Burlison JD, McDaniel RB, Baker DK. , et al. Using EHR data to detect prescribing errors in rapidly discontinued medication orders. Appl Clin Inform 2018; 9 (01) 82-88
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 45 Abraham J, Kannampallil TG, Jarman A. , et al. Reasons for computerised provider order entry (CPOE)-based inpatient medication ordering errors: an observational study of voided orders. BMJ Qual Saf 2018; 27 (04) 299-307
    CrossrefPubMedGoogle Scholar
  • 46 Walsh KE, Adams WG, Bauchner H. , et al. Medication errors related to computerized order entry for children. Pediatrics 2006; 118 (05) 1872-1879
    CrossrefPubMedGoogle Scholar
  • 47 Dornan T, Ashcroft D, Heathfield H. , et al. An in-depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education: EQUIP study. London: General Medical Council; 2009: 1-215 . Available at: https://www.gmc-uk.org/-/media/documents/FINAL_Report_prevalence_and_causes_of_prescribing_errors.pdf_28935150.pdf . Accessed March 13, 2020
    Google Scholar
  • 48 Tolley CL, Forde NE, Coffey KL. , et al. Factors contributing to medication errors made when using computerized order entry in pediatrics: a systematic review. J Am Med Inform Assoc 2018; 25 (05) 575-584
    CrossrefPubMedGoogle Scholar
  • 49 Singh H, Mani S, Espadas D, Petersen N, Franklin V, Petersen LA. Prescription errors and outcomes related to inconsistent information transmitted through computerized order entry: a prospective study. Arch Intern Med 2009; 169 (10) 982-989
    CrossrefPubMedGoogle Scholar
  • 50 Hoonakker PL, Carayon P, Brown RL, Cartmill RS, Wetterneck TB, Walker JM. Changes in end-user satisfaction with Computerized Provider Order Entry over time among nurses and providers in intensive care units. J Am Med Inform Assoc 2013; 20 (02) 252-259
    CrossrefPubMedGoogle Scholar
  • 51 Gates PJ, Meyerson SA, Baysari MT, Lehmann CU, Westbrook JI. Preventable adverse drug events among inpatients: a systematic review. Pediatrics 2018; 142 (03) e20180805
    CrossrefPubMedGoogle Scholar
  • 52 Seidling HM, Bates DW. Evaluating the impact of health IT on medication safety. Stud Health Technol Inform 2016; 222: 195-205
    PubMedGoogle Scholar
  • 53 Sheikh A. Realising the potential of health information technology to enhance medication safety. BMJ Qual Saf 2020; 29 (01) 7-9
    CrossrefPubMedGoogle Scholar
  • 54 Lewis PJ, Dornan T, Taylor D, Tully MP, Wass V, Ashcroft DM. Prevalence, incidence and nature of prescribing errors in hospital inpatients: a systematic review. Drug Saf 2009; 32 (05) 379-389
    CrossrefPubMedGoogle Scholar