Response to Medication Dosing Alerts for Pediatric Inpatients Using a Computerized Provider Order Entry System
07 July 2011
accepted: 15 November 2011
16 December 2017 (online)
Objective: Medication dosing errors are of particular concern in hospitalized children. Avoidance of such errors is essential to quality improvement and patient safety. Computerized provider order entry (CPOE) systems with clinical decision support (CDS) have the potential to reduce medication errors. The objective of this study was to evaluate provider response to the dosing alerts in a CPOE system with CDS for pediatric inpatients and to identify differences in provider response based on clinician specialty.
Patients and methods: We conducted a retrospective analysis of all medication dosing alerts over a 1-year period (January 1 through December 31, 2008) for all pediatric inpatients at Hospital for Special Surgery. Alerts were analyzed with respect to medication dosing, prescriber, and action taken by the prescriber after the alert was triggered (i.e., accepted suggested change, ignored recommendation/overrode, or cancelled the order).
Results: During the study period, 18,163 medication orders were placed and 1,024 dosing alerts were fired. Overdosing of medications accounted for 91% of the alerts and underdosing 9%. The pediatric-trained providers ignored more alerts and cancelled fewer orders than the non-pediatric-trained providers (p<0.001). Both groups changed the order similarly based on CDS recommendations.
Conclusions: Differences in response to CDS were found between pediatric-trained and non-pediatric-trained providers caring for pediatric patients; however, both groups changed orders based on CDS similarly. CPOE with built-in CDS may be of particular value when providers with different specialties and types of training are caring for pediatric patients.
- 1 Kaushal R, Bates DW, Landrigan C, McKenna KJ, Clapp MD, Federico F. et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001; 285: 2114-2120.
- 2 Shaha SH, Brodsky L, Leonard MS, Cimino MA, McDougal SA, Pilliod JM, Martin KE. Establishing a culture of patient safety through a low-tech approach to reducing medication errors. Advances in Patient Safety: From Research to Implementation, vol. 3. Rockville, MD: US Agency for Healthcare Research and Quality; 2005: 333-346.
- 3 Cimino M, 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: 124-132.
- 4 Holdsworth MT, Fichtl RE, Raisch DW, Hewryk A, Behta M, Mendez-Rico E. et al. Impact of computerized prescriber order entry on the incidence of adverse drug events in pediatric inpatients. Pediatrics 2007; 120: 1058-1066.
- 5 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: 59-63.
- 6 Peterson JF, Kuperman GJ, Shek C, Bates DW. Physician responses to life-threatening drug-drug interaction alerts. J Gen Intern Med 2001; 16: 212.
- 7 Van der Sijs H, Aarts J, Vulto A, Berg M. Overriding of drug safety alerts in computerized physician order entry. J Am Med Inform Assoc 2006; 13: 138-147.
- 8 Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety. A systematic review. Arch Intern Med 2003; 163: 1409-1416.
- 9 Magid S, Pancoast P, Fields T, Bradley D, Williams R. Employing clinical decision support to attain our strategic goal: the safe care of the surgical patient. JHIM 2007; 18-25.
- 10 ISMP’s list of high-alert medications [Internet]. Horsham, PA: Institute for Safe Medication Practices. [updated 2008; cited 7/6/2011]. Available from: www.ismp.org/tools/highalertmedications.pdf.
- 11 Custer JW, Rau RE, Lee CKK. Johns Hopkins Hospital. Children’s Medical and Surgical Center. The Harriet Lane handbook. St. Louis, Mo.; London: Elsevier Mosby; 2008
- 12 Thomson Micromedex healthcare series tutorial [Internet]: [Thomson Micromedex; cited 7/7/2011]. Available from: http://www.micromedex.com/support/training/online_tutorials/hcs/modules/module_2/s01_04.htm.
- 13 Institute for Healthcare Improvement: Campaign [Internet]. Cambridge, MA: Institute for Healthcare Improvement; 2008; cited 7/6/2011]. Available from: http://www.ihi.org/IHI/Programs/Campaign.
- 14 Stucky ER. American Academy of Pediatrics Committee on Drugs, American Academy of Pediatrics Committee on Hospital Care. Prevention of medication errors in the pediatric inpatient setting. Pediatrics 2003; 112 (02) 431-436.
- 15 Walton R, Dovey S, Harvey E, Freemantle N. Computer support for determining drug dose: systematic review and meta-analysis. BMJ 1999; 318: 984-990.
- 16 Hunt DL, Haynes RB, Hanna SE, Smith K. Effects of computer-based clinical decision support systems on physician performance and patient outcomes. JAMA 1998; 280: 1339-1349.
- 17 Fortescue EB, Kaushal R, Landrigan CP, McKenna KJ, Clapp MD, Federico F. et al. Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients. Pediatrics 2003; 111: 722-729.
- 18 Kirk RC, Goh DL, Packia J, Kam HM, Ong BKC. Computer calculated dose in paediatric prescribing. Drug Safety 2005; 28 (09) 817-824.
- 19 Van der Sijs H, Van Gelder T, Vulto A, Berg M, Aarts J. Understanding handling of drug safety alerts: a simulation study. IJMI 2010; 79: 361-369.
- 20 Weingart SN, Toth M, Sands DZ, Aronson MD, Davis RB, Phillips RS. Physicians’ decisions to override computerized drug alerts in primary care. Arch Intern Med 2003; 163: 2625-2631.
- 21 Hseih TC, Kuperman GJ, Jaggi T, Hojnowski-Diaz P, Fiskio J, Williams DH. et al. Characteristics and consequences of drug-allergy alert overrides in a computerized physician order entry system. J Am Med Inform Assoc 2004; 11: 482-491.
- 22 Abookire SA, Teich JM, Sandige H, Paterno MD, Martin MT, Kuperman GJ. et al. Improving allergy alerting in a computerized physician order entry system. Proc AMIA Symp 2000; 2-6.
- 23 Taylor L, Tamblyn R. Reasons for physician non-adherence to electronic drug alerts. Medinfo 2004; 11: 1101-1105.
- 24 Killelea BK, Kaushal R, Cooper M, Kuperman GJ. To what extent do pediatricians accept computer-based dosing suggestions?. Pediatrics 2007; 119: 69-75.
- 25 McCoy AB, Waitman LR, Lewis JB, Wright JA, Choma DP, Miller RA. et al. A framework for evaluating the appropriateness of clinical decision support alerts and responses. JAMIA. 2011 amiajnl-2011-000185.