The Role of Health Information
Technology in Medication Safety
Wednesday, April 25, 2007
12:00 – 1:00 p.m. EDT
Moderator:
Paul Sharek, MD, MPH, FAAP
Assistant Professor of Pediatrics, Stanford School of Medicine
Medical Director of Quality Management
Chief Clinical Patient Safety Officer
Lucile Packard Children’s Hospital
Palo Alto, California
This activity was funded through an educational
grant from the Physicians’ Foundation for Health
Systems Excellence.
Disclosure of Financial Relationships and
Resolution of Conflicts of Interest for AAP CME Activities Grid
The AAP CME program aims to develop, maintain, and increase the competency, skills, and
professional performance of pediatric healthcare professionals by providing high quality,
relevant, accessible and cost-effective educational experiences. The AAP CME program
provides activities to meet the participants’ identified education needs and to support their
lifelong learning towards a goal of improving care for children and families (AAP CME
Program Mission Statement, August 2004).
The AAP recognizes that there are a variety of financial relationships between individuals and
commercial interests that require review to identify possible conflicts of interest in a CME
activity. The “AAP Policy on Disclosure of Financial Relationships and Resolution of Conflicts
of Interest for AAP CME Activities” is designed to ensure quality, objective, balanced, and
scientifically rigorous AAP CME activities by identifying and resolving all potential conflicts of
interest prior to the confirmation of service of those in a position to influence and/or control
CME content. The AAP has taken steps to resolve any potential conflicts of interest.
All AAP CME activities will strictly adhere to the 2004 Updated Accreditation Council for
Continuing Medical Education (ACCME) Standards for Commercial Support: Standards to
Ensure the Independence of CME Activities. In accordance with these Standards, the
following decisions will be made free of the control of a commercial interest: identification
of CME needs, determination of educational objectives, selection and presentation of
content, selection of all persons and organizations that will be in a position to control the
content, selection of educational methods, and evaluation of the CME activity.
The purpose of this policy is to ensure all potential conflicts of interest are identified and
mechanisms to resolve them prior to the CME activity are implemented in ways that are
consistent with the public good. The AAP is committed to providing learners with
commercially unbiased CME activities.
DISCLOSURES
Activity Title:
Activity Date:
Safer Health Care for Kids - Webinar
The Role of Health Information Technology in Medication Safety
April 25, 2007
DISCLOSURE OF FINANCIAL RELATIONSHIPS
All individuals in a position to influence and/or control the c ontent of AAP CME activities are required to disclose to
the AAP and subsequently to learners that the individual either has no relevant financial relationships or any
financial relationships with the manufacturer(s) of any commercial product(s) and/or pro vider of commercial services
discussed in CME activities.
Name
Rainu Kaushal, MD,
MPH
Name of
Commercial
Interest(s)*
(*Entity
producing
health care
goods
or services)
Nature of
Relevant
Financial
Relationship(s)
(If yes, please list:
Research Grant,
Speaker’s Bureau,
Stock/Bonds
excluding mutual
funds, Consultant,
Other - identify)
CME Content Will
Include
Discussion/
Reference to
Commercial
Products/Services
Disclosure of Off-Label
(Unapproved)/Investigational Uses of Products
AAP CME faculty are required to disclose to the AAP
and to learners when they plan to discuss or
demonstrate pharmaceuticals and/or medical devices
that are not approved
No
No
No
No
DISCLOSURES
SAFER HEALTH CARE FOR KIDS - PROJECT ADVISORY COMMITTEE AND STAFF
DISCLOSURE OF FINANCIAL RELATIONSHIPS
All individuals in a position to influence and/or control the content of AAP CME ac tivities are required to disclose to the AAP and
subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the
manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in CME activities.
Name
Name of
Commercial
Interest(s)*
(*Entity producing
health care goods
or services)
Nature of Relevant
Financial Relationship(s)
(If yes, please list:
Research Grant, Speaker’s
Bureau, Stock/Bonds
excluding mutual funds,
Consultant, Other - identify)
CME Content Will Include
Discussion/
Reference to Commercial
Products/Services
Disclosure of Off-Label
(Unapproved)/Investigational Uses
of Products
AAP CME faculty are required to
disclose to the AAP and to learners
when they plan to discuss or
demonstrate pharmaceuticals and/or
medical devices that are not approved
Karen Frush, MD, FAAP
(PAC Member)
No
No
No
No
Uma Kotagal, MD, MBBS,
MSc, FAAP (PAC Member)
No
No
No
No
Christopher Landrigan, MD,
MPH, FAAP (PAC Member)
No
No
No
No
Marlene R. Miller, MD, MSc,
FAAP (PAC Chair)
No
No
No
No
Paul Sharek, MD, MPH.
FAAP (PAC Member)
No
No
No
No
Erin Stucky, MD, FAAP (PAC
Member)
No
No
Not sure
No
Nancy Nelson (AAP Staff)
No
No
No
No
Melissa Singleton, MEd
(Project Manager – AAP
Consultant)
No
No
No
No
Junelle Speller (AAP Staff)
No
No
No
No
Linda Walsh, MAB (AAP
Staff)
No
No
No
No
DISCLOSURES
AAP COMMITTEE ON CONTINUING MEDICAL EDUCATION (COCME)
DISCLOSURE OF FINANCIAL RELATIONSHIPS
All individuals in a position to influence and/or control the content of AAP CME ac tivities are required to disclose to the AAP and
subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the
manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in CME activities.
Name
Name of
Commercial
Interest(s)*
(*Entity producing
health care goods
or services)
Nature of Relevant
Financial Relationship(s)
(If yes, please list:
Research Grant, Speaker’s
Bureau, Stock/Bonds
excluding mutual funds,
Consultant, Other - identify)
CME Content Will Include
Discussion/
Reference to Commercial
Products/Services
Disclosure of Off-Label
(Unapproved)/Investigational Uses
of Products
AAP CME faculty are required to
disclose to the AAP and to learners
when they plan to discuss or
demonstrate pharmaceuticals and/or
medical devices that are not approved
Ellen Buerk, MD, FAAP
No
No
No
No
Meg Fisher, MD, FAAP
No
No
No
No
Robert A. Wiebe, MD, FAAP
No
No
Not sure
No
Jack Dolcourt, MD, FAAP
No
No
No
No
Thomas W. Pendergrass, MD,
FAAP
No
No
No
No
Beverly P. Wood, MD, FAAP
No
No
No
No
CME CREDIT
The American Academy of Pediatrics (AAP) is
accredited by the Accreditation Council for
Continuing Medical Education to provide continuing
medical education for physicians.
The AAP designates this educational activity for a
maximum of 1.0 AMA PRA Category 1 Credit™.
Physicians should only claim credit commensurate
with the extent of their participation in the activity.
This activity is acceptable for up to 1.0 AAP credit.
This credit can be applied toward the AAP CME/CPD
Award available to Fellows and Candidate Fellows of
the American Academy of Pediatrics.
OTHER CREDIT
This webinar is approved by the National Association of
Pediatric Nurse Practitioners (NAPNAP) for 1.2
NAPNAP contact hours of which 0.3 contain
pharmacology (Rx) content. The AAP is designated
as Agency #17. Upon completion of the program,
each participant desiring NAPNAP contact hours
should send a completed certificate of attendance,
along with the required recording fee ($10 for
NAPNAP members, $15 for nonmembers), to the
NAPNAP National Office at 20 Brace Road, Suite 200,
Cherry Hill, NJ 08034-2633.
The American Academy of Physician Assistants accepts
AMA PRA Category 1 Credit(s)TM from organizations
accredited by the ACCME .
Rainu Kaushal, MD, MPH
Associate Professor of Pediatrics and Public Health,
Weill Medical College of Cornell University
Director of Pediatric Quality and Safety, KCCH at NYPH
New York, New York
The Role of
Health Information Technology
in Medication Safety
April 25, 2007
12:00 – 1:00 p.m. EDT
11
Learning Objectives
Upon completion of this activity, you will be
able to:
 Review the epidemiology of ambulatory
medication safety in pediatrics.
 Describe the role of health information
technology in improving medication safety.
 Utilize specific health information
technology applications.
12
Historical Perspective

In 1925, 4 main types of adverse events
identified for hospitalized patients:
Burns due to hot water
 Delirious patients jumping from hospital
windows
 Accidents connected with hospital elevators
 Mistakes in the use of drugs

Aikens C. Study in the Ethics for Nurses. Philadelphia: Saunders; 1925
13
Patient Safety and Medical Errors Become
a National Concern
November 29, 1999
14
15
IOM Report: Preventing Medication
Errors

One medication error per day per inpatient



Variation across institutions
At least 25% of injuries from medications are
preventable
Annual preventable injuries from medications



380,000-450,000 in hospitals for $3.5 billion
800,000 in long-term care
530,000 in Medicare ambulatory patients for $887 million
16
Preventing Medication Errors:
Recommendations



Patient’s rights and enhancing consumer
information
Utilizing HIT
 Prescribing and transmission of all prescriptions
electronically by 2010
 Appropriate clinical decision support
 Adopt other appropriate technology (eMAR, bar
coding, smart iv pumps)
 Monitor for medication errors
 Standards for HIT
More research
17
 Pediatrics a prime focus area
Overview



Why medication errors occur in children
Pediatric medication error epidemiology
 Inpatient
 Outpatient
Prevention strategies
 HIT
 Safety and quality
 Financial
18
Why medication errors occur in
children






Weight based dosing
Stock medicine dilution
Ten fold errors
Decreased communication abilities
Inability to self-administer medications
Increased vulnerability of young, critically ill
children
 Immature renal and hepatic systems
19
Definitions
Medication Errors
ADEs
Near Misses
20
Comparisons of Adult and Pediatric
Inpatients
Pediatrics
Orders reviewed
Medication errors
Near Misses
ADEs
Preventable ADEs
10,778
616 (5.7%)
115 (1.1%)
26 (0.24%)
5 (0.05%)
Adults**
10,070
530 (5.3%)
35 (0.35%) *
25 (0.25%)
5 (0.05%)
*p value <0.05
**Study performed at Brigham and Women’s Hospital in 1992 using similar
methods
Kaushal et al, JAMA 2001
21
Error Stage for Medication Errors
Ordering
74%
Transcribe
10%
Dispense
13%
Administer
2%
Monitor
1%
22
Near Misses in the NICU per 100 orders
3
2.8
2.5
2
1.5
1.3
*
1
0.77
*
0.5
0.35
*
0
NICU
JAMA 2001;285;2114-20
PICU
Med/Surg
Adult
* P<0.001
23
Ambulatory Setting: Medication Errors



2952 medication
errors
 1.6 errors per
patient
 1.3 errors per
prescription
521 (12%) rx
inappropriate
abbreviation
1389 (64%) rx
partially illegible
Weight
Other
Dose
Route
Amount
Strength
24
Preliminary Results For Six Office
Practices
Rate
N
95% CI
3%
57
3-4
Non-preventable ADEs 13%
226
11-15
Ameliorable ADEs
9%
152
7-10
Non-intercepted Near
Misses
25%
455
22-29
Preventable ADEs
25
Stages
Preventable ADEs
Administering
Ordering
Dispensing
Transmitting
Near Misses
Administering
Ordering
Dispensing
Transmitting
26
Why Do Errors Occur?



Physician writes an order
Nursing, pharmacist, and clerical staff
mechanisms are in place to carry out orders
What occurs in reality?
27
We deliver medications in hospitals in a manner that
essentially hasn’t changed in 60 years.
pharmacist checks nurse checks patient,
physician writes order
order/allergies
drug, dose, route, time
nurse administers
pharmacist checks
secretary transcribes
drug
drug interactions
Is a double check
pharmacy tech loads
nurse double checks
necessary?
drawer
pharmacy tech places Is drug administered
secretary faxes
drawer in delivery system
via pump
pharmacist receives
nurse obtains drug
fax
from delivery system If order incorrect:
pharmacist enter
nurse checks drug multiple other steps
order
against med sheets
28
We deliver medications in hospitals in a manner that
essentially hasn’t changed in 60 years.
pharmacist checks nurse checks patient,
physician writes order
order/allergies
drug, dose, route, time
nurse administers
pharmacist checks
secretary transcribes
drug
drug interactions
Is a double check
pharm. tech loads
nurse double checks
necessary?
drawer
pharm. tech places Is drug administered
secretary faxes
drawer in meditrol
via pump
pharmacist receives
nurse obtains drug
fax
from meditrol
If order incorrect:
pharmacist enter
nurse checks drug multiple other steps
order
against med sheets
29
The Role of Complexity in
Preventing Errors

Probability of Performing Perfectly:
Probability of success, each element:
# of elements
0.95
1
25
50
100
0.95
0.28
0.08
0.006
0.99
0.99
0.78
0.61
0.37
0.999
0.999
0.96
0.95
0.90
0.9999
0.9999
0.998
0.995
0.99
30
No one makes an error on purpose.
Lucian Leape
31
Everyone makes dumb mistakes every
day.
32
No one admits an error if you punish
them for it.
33
Error Reduction: Systems Approach

Culture of Safety
 Non-punitive systems
 Multidisciplinary error prevention

Involve parents and families
Executive walk rounds
 Medication Safety Initiative


Strong, clear, visible attention to safety

Avoid fatigue
Minimize distractions
Independent double checks
nd checker will detect ~ 90% of errors made by
2
first checker

HIT


34
How will HIT help?




Improve communication
 What has been done and by whom
Improve accessibility
 Paper records unavailable 1/3 of the time
 Physicians spend 20-30% of their time searching
for and organizing information
Require key pieces of information
Improve information retrieval
 Impossible to store all needed clinical information
in a physician’s head
35
How will HIT help? (cont)



“Just in time” decision support
 Assist with calculations
 Make the right thing the easiest to do
 Perform checks in real-time
Assist with monitoring
Advance the quality agenda
 Quality measurement
 Low cost way to diffuse evidence-based best
practices
36
Impact of HIT on Quality, Efficiency and
Costs


4 Benchmark institutions
Quality




Efficiency


Increased adherence to guidelines
Enhanced surveillance and monitoring
Medication errors
Decreased utilization of care
Financial
Chaudhry B et al, Annals 2006
37
Types of HIT







EHR, Electronic health record
CPOE, Computerized physician order entry
Robots
Smart IV systems
Bar coding
Telemedicine
Automated drug delivery systems
38
CPOE: Low hanging fruit
Illegible handwriting
 Incomplete information
 Unacceptable Abbreviations
 Lack of leading zeros
 Inclusion of trailing zeros

39
Key Areas of Decision Support








Requiring complete orders
Default doses
Drug-allergy checking
DDI checking
Renal dosing
Geriatric dosing
Drug-lab checking
Dose ceilings
40
Handwriting example
41
“Corollary” order reminders reduce errors
of omission

Target - corollary order pairs (n=87)
NSAID – creatinine level
 Aminoglycoside – drug levels, creatinine
 Warfarin – routine protimes


Intervention -- display reminder at time of
ordering
Overhage JAMIA 1997;4:364-375
42
Effect of alerts on compliance
Overhage JAMIA 1997;4:364-375
43
Proportion of doses exceeding
recommended maximum
2.50%
2.10%
2.00%
1.50%
1.00%
0.60%
0.50%
0.00%
Paper-based
Computer ordering
Teich Archives Int Med 2000;160:2741
44
Dosing appropriateness in patients with
renal impairment
70%
60%
50%
40%
30%
20%
10%
0%
67%
54%
59%
35%
Dose
appropriate
Intervention
Both results
P < 0.001
Frequency
appropriate
Control
Chertow JAMA 2001;286:2839-44
45
Effect of an antibiotic advisor
146
160
140
120
100
80
60
40
20
0
500
405
400
300
35
200
87
100
Orders for drugs to which
patient is allergic
250
0
206
Excess drug dosages
30
200
25
150
20
15
100
50
12
0
Antibiotic-susceptibility
mismatches
All results statistically significant
Costs, LOS also reduced
Evans NEJM 1998;338:232-238
28
10
5
0
4
ADEs caused by antiinfective
agent
Intervention
Control
46
Effect of Changing Default Dosing
Frequency for Ceftriaxone
60
40
BID
QD
30
20
10
Week
17
15
13
11
9
7
5
3
0
1
Orders/week
50
NYPH -- Pediatric dosing decision support
Computer suggests
300 mg every 8 hours
for this patient; based
on age and weight
Evaluation
•32% of
suggestions
accepted
exactly
•Good reasons
for not
following
•Subjectively,
physicians like
it
(Killela B, et al;
Pediatrics, 2007)
48
Results of Two Studies on Medication
Error Prevention


CPOE reduced medication errors by 80%
CPOE reduced serious medication errors by
55%
Bates et al, JAMA 1998
Evidence of Reduction in Errors

CPOE Pittsburgh Children’s
 Harmful ADEs pre-CPOE 0.05/1000 doses
 Post-CPOE 0.03/1000 doses (p=0.05).
 CPOE prevents 1 ADE every 64 patient days
Upperman et al. J Pediatr Surg 2005;40:57-59
50
Evidence of Reduction in Errors


Mullett
 Stand alone anti-infective CDSS in PICU
 59% decrease in the rate of pharmacy
interventions for wrong drug doses
Potts
 CPOE and medication ordering errors in PICU
 Medication errors reduced 96%

Near misses reduced 41%
Mullett CJ, et al. Pediatrics 2001;108:75-81
Potts AL, et al. Pediatrics 2004;113:59-63
51
So what’s the problem?





High federal and state policy interest
Leapfrog group identified as 1 of 3 patient safety
‘leaps’
Only 10-15% of hospitals across the country have
active CPOE systems
Few primary care physicians have CPOE
High stakes
 Enormous institutional investment
 Well-publicized ‘failures’
52
Unintended Consequences

“I have ordered the test that was right next
to the one I thought I ordered, you know,
right below it that little thingie had come
down and I clicked and I’m lookin’ at this
one but I in fact clicked on the thing before.
By that time I turned my head and I’m
hitting return and typing my signature and
not seeing it.”
Ash, JAMIA 2005
53
$$$,$$$,$$$

High cost and lack of capital


Cost benefit mis-match


“The number one [barrier] is cost. I have been doing
hospital software for 29 years, and this is the most
expensive project I’ve ever done.”
“[CPOE] may save a lot of money [for] the health care
system overall, but [the money] is not being collected
by the hospital.”
For ambulatory CPOE, assuming 11.6% capitation
rate nationally
 11% of ROI accrues to providers
 89% to other stakeholders, primarily payers
54
Errors in Administration
IV Infusions



Rule of 6’s intended for rapid dose calculation and
drug preparation
 If:
conc of drug (mL/100 ml) = 6 x patient weight (kg)
 Then:
dose (µg/kg per min) = rate (mL/hour)
Calculation intensive
Numerous possible concentrations
 If use standard drug concentrations, then rely on
dosing charts
55
Errors in Administration
IV Infusions

IV syringe pumps

Traditional infusion pumps prone to ADEs
Errors due to keypad data entry mistakes
 Free-flow phenomena

56
Smart Pumps

Library of medications with standard
concentrations specific to patient population

Makes calculations

“Safety net”

Hard limits (range cannot be overridden)

Soft limits (can be overridden)

Pump alarms and halts infusion if medication
dose is programmed outside preset limits
57
Smart Pump with Standard Concentrations and
Redesigned Labels
3.5
3
2.5
Reported
Errors
2
1.5
1
*
0.5
0
Preintervention
Errors, per 1000
doses
Larsen et al. Pediatrics 2005
Postintervention
Errors, per 1000
doses
*p<0.001
58
Safe Practices for Communicating Test Results

Critical ambulatory safety issue

75% of physicians did not notify patients
of normal results

33% of physicians did not even notify of
abnormal results (Boohaker et al, Archives
1996)

Approximately 1/3 of women with
abnormal mammograms or pap smears do
not receive appropriate follow-up care
59
Improving Result Management Systems






Can be integrated with Electronic Medical Records
A tool that allows focus on truly abnormal test
results
A tool that warns physicians if patients have missed
tests
Use of standardized features, such as “ticklers”
Paper systems can also be highly successful
Standardized procedures rather than every physician
doing it his/her own way
60
Results Manager Application
61
Strategy: Automate Carefully
 EHR
 CPOE
 Smart
IV systems
 Robots
 Automated drug delivery systems
 Bar coding
Inexpensive technology
 63% reduction in serious dispensing errors
at BWH

Conclusions

Make safety top priority


Move from a culture of blame to one of safety
Stop blaming people for making errors

To err is human

Improve the system

Utilize technology as it becomes available

Involve patients/parents to the fullest extent

Measure and iteratively refine
63