Outcomes on Implementation of
Electronic Medication Administration
Records and CPOE
Alan Chan, MD
Internal Medicine-Pediatrics
Mentors
• Michael Huke, Pharm D.
• Melissa Gabriel, Pharm.D., BCPS
• Jeff Hackman, MD – Emergency Dept.
Disclaimer
• I was working on the CDC Universal Data
Collection project for hemophilia and other
blood disorders for adult and pediatrics.
• A couple months ago, the project was shelved
due to funding cuts and delays.
• I’m not sure if I should blame the federal
budget cuts…
• Full statistical analysis is not completed.
Background
• Something big happened at the end of
August 2010!
• Cerner GO-Live/Q6 for the CPOE (or
Computer Physician Order entry) !!!
• This will be referred to as the “start
date”.
The Institute of Medicine
• In 1999 article, notes 44,000 to 98,000 deaths
due to medical errors.
• To what extent these are directly related are
debatable.
• Computer physician order entry is one of the
benchmarks for patient safety.
• Defined by Leapfrog Group along with ICU
staffing, High risk treatments/procedures, and
Safe Practices Score
• Also part of HITECH Act of 2009.
•
http://www.leapfroggroup.org/for_consumers/hospitals_asked_what accessed 4/1/2011
University HealthSystem
Consortium (UHC)
• Consists of 113 academic medical centers and
affialiated hospitals – 90% of nations nonprofits academic medical centers
• Patient Safety Net (PSN) is a real time, Webbased event reporting system.
• At Truman Medical Center (TMC), events can
be logged into the system by any health care
provider.
•
https://www.uhc.edu/11851.htm accessed 4/1/2011
Objective
• We believe that the initiation of the CPOE and
electronic medication administration record
(eMAR) would decrease total errors.
• What new errors might be introduced?
• Few studies exist to track these changes.
Methods
• Search on PubMed limited to past 5 years,
English print journals, and Humans.
• Terms included “electronic medical records and
patient safety” for 228 results and “Adverse
drug events computer physician order “ with
51 results.
• Some immediate references and citations to
these results were used, which could include
older articles.
•
http://www.ncbi.nlm.nih.gov accessed 4/1/2011
Methods (cont)
• TMC – all areas (inpatient, outpatient, ER, BH)
• CPOE system – Powerchart; Cerner
• A retrospective review of PSN results were
used – these are self reported.
• Time frame of 1, 3, and 6 months pre and
post implementation were used.
• A random sampling of 1 and 3 month windows
were done to ensure similar number of
reports.
Variables
• Looked at ALL medications errors (med errors)
– Sub groups of wrong medication and incorrect
medication list separately and also together.
• Looked at Adverse Drug Reactions (ADR), but
not medication errors.
• In these Med errors, looked at the type of
outcome, whether it created an “Unsafe, No
Harm, or Harmful Event”.
Medication errors – 9 types
1.
2.
3.
4.
5.
6.
7.
8.
9.
Dose omission
Extra dose given
Wrong medication
Prescription/refill delay
Medication list was incorrect
Monitoring error (includes contraindications)
Unauthorized drug
Inadequate pain management
Other
Harm Score or Category of
Events
•
•
•
•
•
Unsafe conditions (A)
Event, but no Harm
– B1 – near miss from chance
– B2 – near miss because of recovery efforts
– C – reached patient (pt), but no harm
– D – reached pt, and required additional monitoring to
prevent harm
Event, but Harm
– E – pt temporary harm, and required treatment
– F – pt temporary harm, and required more hospitalization
– G – permanent harm
– H – harm and required intervention to sustain life like ICU
transfer
Death (I) – one case, but unique circumstance.
Undetermined (X) - no cases
Results – 1 month window
1 month
PRE
POST
ARR %
RRR %
ALL errorsmed error wrong med med list wrong ADR
74
35
28
7
62
23
20
3
12
12
8
4
16.2
34.3
28.6
57.1
PRE = before “start date”; POST = after “start date”; ARR% is
the Absolute risk reduction; RRR % is the relative risk reduction
5
2
3
60
Results – 3 month window
3 month
PRE
POST
ARR %
RRR %
ALL errorsmed error wrong med med list wrong ADR
198
101
79
22
17
174
66
58
8
11
24
35
21
14
6
12.1
34.7
26.6
63.6
35.3
Results – 6 month window
6 month
PRE
POST
ARR %
RRR %
ALL errorsmed error wrong med med list wrong ADR
421
183
136
47
34
289
107
93
14
26
132
76
43
33
8
31.4
41.5
31.6
70.2
23.5
Results…
• A few single months were checked before and
after “start date”, and the overall results
number of reported events are similar
• The overall number of reports have been
increasing over the past few years, so difficult
to access much before the “start date”.
• Overall, all types of errors are lower. **
Results – Harm score
6 month
unsafe
event - no harm event - harm total
PRE
16
393
12
421
POST
30
242
17
289
These are number of medication errors
More errors?
• Why more Unsafe errors?
–
–
–
–
More wrong med errors (from 5 to 10)
New type of error – delay in getting med
A contraindication was displayed and noted
Other types
• Why More Harmful errors?
– Actually less “Omission errors”
– More wrong med errors (from 5 to 7)
– Other types
• The “other types” may be mislabeled**.
Discussion
• User generated reports, although members of the PSN
team here review reports as they are generated in realtime.
• Some other reports may not have been correctly
classified.
• New unintended consequences – one study at a tertiary
pediatric center actually noted increased mortality.
• Might affect time sensitive therapies like critical care
settings.
•
Han YY, Carcillo JA, Venkataraman ST, et al. Unexpected increased mortality after implementation of a
commercially sold computerized physician order entry system
Next steps
• Review 1 year data
• Evaluate whether this represents a fair sample
of the cases.
• Review the “other category” to make sure
properly labeled cases
• Look at ADR and mortality, latter difficult to
evaluate with this.
Notable thoughts.
•
•
•
•
It takes time for providers to adopt
Pharmacy centralizes many medications
Providers may spend more time away from bedside
Physician workload will increase, but uncertain amount
– Is this trade off worth the better documentation and
e-paper trail?
• More order set would decrease “click through” time
• Delays in opening electronic charts during heavy work
times
• Self reported events and ADR may not correlate with
true rate.
Other thoughts
• One study at a pediatric hospital saw overall
decrease in hospital wide mortality with CPOE
and electronic nursing documentation.
• Studies at ICU areas show decrease in risk of
medication errors, but no significant reduction
in ADR or mortality.
• Many studies have not been fully powered to
detect the small number of ADR or mortality
though.
• We can look at 1 year data from “start date”.
References
•
•
•
•
•
•
•
•
http://www.leapfroggroup.org/for_consumers/hospitals_asked_what accessed 4/1/2011
Han YY, Carcillo JA, Venkataraman ST, et al. Unexpected increased mortality after
implementation of a commercially sold computerized physician order entry system [published
correction appears in Pediatrics. 2006;117(2):594]. Pediatrics. 2005;116(6):1506–1512.
Van Rosse F, Maat B, Carin MA, et al. The Effect of CPOE on Medication Prescription Errors
and Clinical Outcome in Pediatric and Intensive Care: A Systemic Review. Pediatrics. 2009;
123(4): 1184-1190.
Sittig DF, Ash JS, Zhang J, et al. Lessons From "Unexpected Increased Mortality After
Implementation of a Commercially Sold Computerized Physician Order Entry System“.
Pediatrics. 2006; 118; 797-801.
Longhurst CA, Parast L, Sandbord CI, et al. Decrease in Hospital-wide Mortality Rate After
Implementation of a Commercially Sold Computerized Physician Order Entry System.
Pediatrics. 2010; 126: 14-21.
Kaushal R, Shojania KG, Bates DW. Effects of Computerized Physician Order Entry and Clinical
Decision Support Systems on Medication Safety. Arch Intern Med. 2003; 163: 1409-1416.
http://www.cpoe.org/ From Oregon Health and Sciences University. Accessed 4/1/2011