#16
PROJECT NAME: Controlling antibiotics dosing errors in
patients with impaired renal function using an EMR alert
Institution: UTMB Galveston
Primary Author: Hudali, Tamer MD
Secondary Author: Low, Leah MD., Almomani, Ahmed MD., Masel, Meredith
PHD. MSSW.
Project Category: General Quality Improvement
Overview:
Frequently medication dosing is not adjusted according to the glomerular
filtration rate (GFR) resulting in many avoidable adverse outcomes such as
worsening renal function, medication toxicity, and death. This problem originates
from either decreased awareness of the patient’s estimated GFR and/or a lack of
knowledge regarding the prescribed medication.
This quality improvement project was intended to decrease the rate of dosing
errors in patients with impaired renal function and to increase both patient and
physician awareness of kidney function. The idea was to start with a group of
medications (antibiotics) that commonly requires renal dosing adjustment and then
broaden the intervention to include different kinds of medications and interventions
(IV contrast introduction and chemotherapy for instance).
A team of physicians, nurses, pharmacists and IT staff were grouped to
review the process of antibiotic administration. The project began in August 2012
with a data collection from EPIC (the electronic medical record system used at
UTMB) to assess the rates of dosing errors based on the patient’s GFR at the time of
ordering. Data from a three month period was assessed, followed by a repeat
assessment after the intervention. The data were collected from medical floors that
were covered by internal medicine and family medicine services at John Sealy
hospital, UTMB.
Purpose/Aim:
Our aim is to reduce antibiotics dosing errors in renally impaired patients by 20% in
a 3 month period (by March 2013) through implementing a best practice alert in our EMR.
Tools and Measurement:
The following quality tools have been used:
Fish bone Diagram:
Process flow chart:
Intervention and Improvement:
After discussing the possible areas of intervention and reviewing the fishbone
diagram and process flow chart, we chose the EMR as the tool for intervention.
Six antibiotics were chosen based on the frequency of use in our institution. These
antibiotics are: Vancomycin, Piperacillin-Tazobactam, Levofloxacin, Cefepime, Ertapanem
and Meropenem. With the help of our IT department, 2321 antibiotic orders were collected
and reviewed to assess for the rates of wrong dosing based on the GFR at the time of
dosing. The GFR was calculated manually for each patient using the MDRD formula.
Patients with acute kidney injury were excluded from this data analysis. The clinical
indications for antibiotics were considered when assessing the appropriate dose and the
dose that needs adjustment.
Ideally, we would like our EMR to recognize a patient with impaired renal function,
recognize the antibiotic being ordered needs adjustment, and recommend the appropriate
dosing using dosing guidelines per www.uptodate.com. However, we encountered
technical difficulties and were unable to implement this system. Instead, the alert we
formulated is a best practice alert that provides the ordering staff with the current GFR
based on the current creatinine. The EMR will prompt the provider with a link to the
uptodate website to help determine the appropriate dose:
The alert was launched on January 1st 2013. A presentation was given to the
internal medicine residents during morning report explaining the implications and the
purpose of the alert.
One thousand one hundred and sixteen antibiotics orders were reviewed (with the
same criteria described above) in a 2 month period after the release of the EMR alert.
Intervention Results:
We compared dosing error rates between the two sets of data collected before and
after the intervention. Patients on dialysis were studied separately.
As shown above, the total error percentage decreased significantly after the alert
system was launched. The percentage of errors before the intervention was 15.4%, and the
percentage of errors after the intervention was 3.7%. To assess the significance of these
results, a one sided Z-score was performed. Z score: 9.5002 with a P value of < 0.000001.
Table 1: Pre-intervention Data
Correct dose
Wrong dose
Total
Antibiotics orders
1856
338
2194
percentage
84.6%
15.4%
100%
Antibiotics orders
959
37
996
percentage
96.3%
3.7%
100%
Table 2: Post-intervention Data
Correct dose
Wrong dose
Total
The same analysis was conducted on data obtained from dialysis patients, however
no significant difference was found between the 2 groups.
The following graphs illustrate the reduction in errors rates shown in all antibiotic
groups:
A cost-effectiveness analysis is currently being conducted and results are pending.
We anticipate a significant cost reduction associated with the reduction in incorrect dosing.
Revenue Enhancement /Cost Avoidance / Generalizability:
After reviewing the results and following the PDSA cycle, multiple areas of
improvement in our intervention were identified. In the future, we would like to include
patients with AKI by adding a best practice alert that identifies a change in creatinine of
more than 50% or more than 0.3 mg/dl (as per current guidlines). This alert will signal an
ordering provider that the patient’s renal function has changed and antibiotics need
adjustment. We also feel it is imperative to include patients on dialysis and plan to add an
addendum to our current alert notifying the provider when a patient has end stage renal
disease.
Our intervention has decreased the cost of health care by two aspects. First, we have
avoided unnecessary doses of antibiotics to patients with renal impairment without
affecting treatment rate or outcome. Second, we have decreased the rate of possible adverse
outcomes and potential harm that may occur when overdosing antibiotics and failing to
complying with the current guidelines regarding renal dosing of antibiotics.
Because we achieved highly significant results with a fairly simple intervention, in
the future we would like to generalize the alert to include all medications that require renal
adjustment. Additionally, we would like the alert to include procedures requiring contrast
that may harm patients with renal impairment such as imaging and cardiac catheterizations.