Computerized physician order entry and electronic medical record systems in Korean teaching and general hospitals: results of a 2004 survey.
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OBJECTIVE: To determine the availability of computerized physician order entry (CPOE) and electronic medical record (EMR) systems in teaching and general hospitals in the Republic of Korea. DESIGN: A combined mail and telephone survey of 283 hospitals. MEASUREMENTS: The surveys assessed the availability of CPOE and EMRs in the hospitals, as well as inducement, participation, and saturation regarding CPOE use by physicians. RESULTS: A total of 122 (43.1%) hospitals responded to the survey. The complete form of CPOE was available in 98 (80.3%) hospitals. The use of CPOE was mandatory in 92 (86.0%) of the 107 hospitals that responded to the questions regarding the requirement of CPOE use. In 85 (79.4%) of the hospitals in which CPOE was in use, more than 90% of physicians used the system. In addition, physicians entered more than 90% of their total orders through CPOE in 87 (81.3%) hospitals. In contrast, a complete EMR system was available in only 11 (9.0%) of the hospitals. CONCLUSION: Of the teaching and general hospitals in the Republic of Korea that responded to the survey, the majority (80.3%) have CPOE systems, and a complete EMR system is available in only 9%. (+info)
Outpatient prescribing errors and the impact of computerized prescribing.
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BACKGROUND: Medication errors are common among inpatients and many are preventable with computerized prescribing. Relatively little is known about outpatient prescribing errors or the impact of computerized prescribing in this setting. OBJECTIVE: To assess the rates, types, and severity of outpatient prescribing errors and understand the potential impact of computerized prescribing. DESIGN: Prospective cohort study in 4 adult primary care practices in Boston using prescription review, patient survey, and chart review to identify medication errors, potential adverse drug events (ADEs) and preventable ADEs. PARTICIPANTS: Outpatients over age 18 who received a prescription from 24 participating physicians. RESULTS: We screened 1879 prescriptions from 1202 patients, and completed 661 surveys (response rate 55%). Of the prescriptions, 143 (7.6%; 95% confidence interval (CI) 6.4% to 8.8%) contained a prescribing error. Three errors led to preventable ADEs and 62 (43%; 3% of all prescriptions) had potential for patient injury (potential ADEs); 1 was potentially life-threatening (2%) and 15 were serious (24%). Errors in frequency (n=77, 54%) and dose (n=26, 18%) were common. The rates of medication errors and potential ADEs were not significantly different at basic computerized prescribing sites (4.3% vs 11.0%, P=.31; 2.6% vs 4.0%, P=.16) compared to handwritten sites. Advanced checks (including dose and frequency checking) could have prevented 95% of potential ADEs. CONCLUSIONS: Prescribing errors occurred in 7.6% of outpatient prescriptions and many could have harmed patients. Basic computerized prescribing systems may not be adequate to reduce errors. More advanced systems with dose and frequency checking are likely needed to prevent potentially harmful errors. (+info)
The effect of automated alerts on provider ordering behavior in an outpatient setting.
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BACKGROUND: Computerized order entry systems have the potential to prevent medication errors and decrease adverse drug events with the use of clinical-decision support systems presenting alerts to providers. Despite the large volume of medications prescribed in the outpatient setting, few studies have assessed the impact of automated alerts on medication errors related to drug-laboratory interactions in an outpatient primary-care setting. METHODS AND FINDINGS: A primary-care clinic in an integrated safety net institution was the setting for the study. In collaboration with commercial information technology vendors, rules were developed to address a set of drug-laboratory interactions. All patients seen in the clinic during the study period were eligible for the intervention. As providers ordered medications on a computer, an alert was displayed if a relevant drug-laboratory interaction existed. Comparisons were made between baseline and postintervention time periods. Provider ordering behavior was monitored focusing on the number of medication orders not completed and the number of rule-associated laboratory test orders initiated after alert display. Adverse drug events were assessed by doing a random sample of chart reviews using the Naranjo scoring scale. The rule processed 16,291 times during the study period on all possible medication orders: 7,017 during the pre-intervention period and 9,274 during the postintervention period. During the postintervention period, an alert was displayed for 11.8% (1,093 out of 9,274) of the times the rule processed, with 5.6% for only "missing laboratory values," 6.0% for only "abnormal laboratory values," and 0.2% for both types of alerts. Focusing on 18 high-volume and high-risk medications revealed a significant increase in the percentage of time the provider stopped the ordering process and did not complete the medication order when an alert for an abnormal rule-associated laboratory result was displayed (5.6% vs. 10.9%, p = 0.03, Generalized Estimating Equations test). The provider also increased ordering of the rule-associated laboratory test when an alert was displayed (39% at baseline vs. 51% during post intervention, p < 0.001). There was a non-statistically significant difference towards less "definite" or "probable" adverse drug events defined by Naranjo scoring (10.3% at baseline vs. 4.3% during postintervention, p = 0.23). CONCLUSION: Providers will adhere to alerts and will use this information to improve patient care. Specifically, in response to drug-laboratory interaction alerts, providers will significantly increase the ordering of appropriate laboratory tests. There may be a concomitant change in adverse drug events that would require a larger study to confirm. Implementation of rules technology to prevent medication errors could be an effective tool for reducing medication errors in an outpatient setting. (+info)
Improving acceptance of computerized prescribing alerts in ambulatory care.
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Computerized drug prescribing alerts can improve patient safety, but are often overridden because of poor specificity and alert overload. Our objective was to improve clinician acceptance of drug alerts by designing a selective set of drug alerts for the ambulatory care setting and minimizing workflow disruptions by designating only critical to high-severity alerts to be interruptive to clinician workflow. The alerts were presented to clinicians using computerized prescribing within an electronic medical record in 31 Boston-area practices. There were 18,115 drug alerts generated during our six-month study period. Of these, 12,933 (71%) were noninterruptive and 5,182 (29%) interruptive. Of the 5,182 interruptive alerts, 67% were accepted. Reasons for overrides varied for each drug alert category and provided potentially useful information for future alert improvement. These data suggest that it is possible to design computerized prescribing decision support with high rates of alert recommendation acceptance by clinicians. (+info)
The introduction of computerized physician order entry and change management in a tertiary pediatric hospital.
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OBJECTIVES: The objectives of this review were to document the introduction of computerized physician order entry (CPOE)-centered changes in an academic tertiary care center and to review the CPOE-focused literature. DESIGN: We performed a systematic literature review of CPOE-related articles indexed on Medline, with particular emphasis on pediatric applications. We focused our commentary around the concepts involved in the implementation process at a tertiary pediatric hospital. RESULTS: In 2001, the Children's Hospital of Pittsburgh (CHP) embarked on the process of CPOE design and implementation. We determined that CPOE is a tool for improving pediatric care. The CPOE implementation process is more than a technologic change; it involves an organizational cultural transformation. Although the complete transition to CPOE was little more than 1 year ago, CHP has overcome the typical obstacles of CPOE implementation to begin to realize its many benefits. The early success of CHP was achieved by creating a realistic, positive, work environment, which fostered hospital-wide participation and integration. CONCLUSION: CPOE is an invaluable resource for supporting patient safety in health care settings. The successful implementation of CPOE requires a paradigm shift in hospital policies and processes. (+info)
Medication errors: a prospective cohort study of hand-written and computerised physician order entry in the intensive care unit.
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INTRODUCTION: The study aimed to compare the impact of computerised physician order entry (CPOE) without decision support with hand-written prescribing (HWP) on the frequency, type and outcome of medication errors (MEs) in the intensive care unit. METHODS: Details of MEs were collected before, and at several time points after, the change from HWP to CPOE. The study was conducted in a London teaching hospital's 22-bedded general ICU. The sampling periods were 28 weeks before and 2, 10, 25 and 37 weeks after introduction of CPOE. The unit pharmacist prospectively recorded details of MEs and the total number of drugs prescribed daily during the data collection periods, during the course of his normal chart review. RESULTS: The total proportion of MEs was significantly lower with CPOE (117 errors from 2429 prescriptions, 4.8%) than with HWP (69 errors from 1036 prescriptions, 6.7%) (p < 0.04). The proportion of errors reduced with time following the introduction of CPOE (p < 0.001). Two errors with CPOE led to patient harm requiring an increase in length of stay and, if administered, three prescriptions with CPOE could potentially have led to permanent harm or death. Differences in the types of error between systems were noted. There was a reduction in major/moderate patient outcomes with CPOE when non-intercepted and intercepted errors were combined (p = 0.01). The mean baseline APACHE II score did not differ significantly between the HWP and the CPOE periods (19.4 versus 20.0, respectively, p = 0.71). CONCLUSION: Introduction of CPOE was associated with a reduction in the proportion of MEs and an improvement in the overall patient outcome score (if intercepted errors were included). Moderate and major errors, however, remain a significant concern with CPOE. (+info)
What do we know about medication errors made via a CPOE system versus those made via handwritten orders?
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This commentary on the article by Shulman et al. examines what we understand by 'medication errors', what we mean by 'computerized physician order entry (CPOE) systems', how we measure errors, and what types of errors we are 'reducing' with CPOE systems. As the research of Shulman and colleagues highlights, much of the existing research on CPOE systems does not differentiate among: types of medication errors; consequential versus inconsequential medication errors; CPOE systems that include/exclude formal decision support packages; and the extent to which decision support information is implicitly presented to physicians via the CPOE system, for example, pull down menus with dosages. I discuss these issues and their implications for the evaluation of CPOE systems and of other emerging healthcare technologies. (+info)
U.S. adoption of computerized physician order entry systems.
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Computerized physician order entry (CPOE) has been shown to reduce preventable, potential adverse events. Despite this evidence, fewer than 5 percent of U.S. hospitals have fully implemented these systems. We assess empirically alternative reasons for low CPOE implementation using data from various sources. We find that CPOE is related to hospital ownership and teaching status; government and teaching hospitals are much more likely than other hospital types are to invest in CPOE. Hospital profitability is not associated with CPOE investment. Although greater diffusion of CPOE is needed, it might have to await continuing publicity efforts and substantial reimbursement system changes. (+info)