Monitoring pharmacy expert system performance using statistical process control methodology.
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Automated expert systems provide a reliable and effective way to improve patient safety in a hospital environment. Their ability to analyze large amounts of data without fatigue is a decided advantage over clinicians who perform the same tasks. As dependence on expert systems increase and the systems become more complex, it is important to closely monitor their performance. Failure to generate alerts can jeopardize the health and safety of patients, while generating excessive false positive alerts can lead to valid alerts being dismissed as noise. In this study, statistical process control charts were used to monitor an expert system, and the strengths and weaknesses of this technology are presented. (+info)
Will decision support in medications order entry save money? A return on investment analysis of the case of the Hong Kong hospital authority.
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The computerized medications order entry system currently used in the public hospitals of Hong Kong does not have decision support features. Plans are underway to add decision support to this system to alert physicians on drug-allergy conflicts, drug-lab result conflicts, drug-drug interactions and atypical dosages. A return on investment analysis is done on this enhancement, both as an examination of whether there is a positive return on the investment and as a contribution to the ongoing discussion of the use of return on investment models in health care information technology investments. It is estimated that the addition of decision support will reduce adverse drug events by 4.2 - 8.4%. Based on this estimate, a total net saving of $44,000 - $586,000 is expected over five years. The breakeven period is estimated to be between two to four years. (+info)
How the ICU follows orders: care delivery as a complex activity system.
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In this paper, we use the theory of distributed cognition to understand work practices in terms of the behavior of an activity system. We do so by detailing the roles that local representations of information play in the social, cognitive, organizational, and technological processes that accomplish task work. Specifically, we characterize a portion of the medication order process in an Intensive Care Unit. In this setting, the processes that execute a medication order have evolved to accomplish the primary tasks of medication administration and also to simultaneously support other important aspects of the unit's work. Designers of systems that centralize and automate information resources must consider the diverse and latent roles played by information in order to improve design and to anticipate how their products affect complex care delivery systems. (+info)
Critical gaps in the world's largest electronic medical record: Ad Hoc nursing narratives and invisible adverse drug events.
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The Veterans Health Administration (VHA), of the U.S. Department of Veteran Affairs, operates one of the largest healthcare networks in the world. Its electronic medical record (EMR) is fully integrated into clinical practice, having evolved over several decades of design, testing, trial, and error. It is unarguably the world's largest EMR, and as such it makes an important case study for a host of timely informatics issues. The VHA consistently has been at the vanguard of patient safety, especially in its provider-oriented EMR. We describe here a study of a large set of adverse drug events (ADEs) that eluded a rigorous ADE survey based on prospective EMR chart review. These numerous ADEs were undetected (and hence invisible) in the EMR, missed by an otherwise sophisticated ADE detection scheme. We speculate how these invisible nursing ADE narratives persist and what they portend for safety re-engineering. (+info)
Creating an enterprise-wide allergy repository at Partners HealthCare System.
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A significant fraction of medication errors and preventable adverse drug events are related to drug-allergy interactions (DAIs). Computerized prescribing can help prevent DAIs, but an accurate record of the patient's allergies is required. At Partners HealthCare System in Boston, the patient's allergy list is distributed across several applications including computer physician order entry (CPOE), the outpatient medical record, pharmacy applications, and nurse charting applications. Currently, each application has access only to its own allergy data. This paper presents details of a project designed to integrate the various allergy repositories at Partners. We present data documenting that patients have allergy data stored in multiple repositories. We give detail about issues we are encountering such as which applications should participate in the repository, whether "NKA" or "NKDA" should be used to document known absence of allergies, and which personnel should be allowed to enter allergies. The issues described in this paper may well be faced by other initiatives intended to create comprehensive allergy repositories. (+info)
Validation of automated event triggers using laboratory values related to two problem-prone drugs.
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We used computerized alerts to identify patients with laboratory values that could be related to medication errors associated with digoxin and warfarin. Over a six-week period at two inpatient facilities, we generated 62 laboratory-based alerts for warfarin, and 66 for digoxin. The positive predictive value for these alerts representing a preventable event was 71% and 57% for warfarin and digoxin, respectively. (+info)
Evaluation of standardized tasks for primary care physicians using the MOXXI electronic prescribing and integrated drug management system.
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The Medical Office for the Twenty First Century (MOXXI) is a research project testing the potential benefits of an electronic prescription and drug management system for primary care physicians. This system includes a dynamic electronic pad for prescription entry with fields for treatment indications; a drug profiler with a graphic representation of the list of prescription medications purchased in the last year; a refill compliance calculator; dates of emergency room visits and hospital admissions; cost of drugs dispensed; and an alert system that detects interactions among drugs, treatment duplications, and contraindications with certain allergies or specific diseases. One concern expressed by physicians that could influence uptake and acceptability is the increased time that may be required to use the system. User abilities are a factor in this process, as well as user interface, user training and system speed. (+info)
A real time interface between a computerized physician order entry system and the computerized ICU medication administration record.
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Prior attempts to interface ICU Clinical Information Systems (CIS) to Pharmacy systems have been less than successful. The major problem is that in ICUs, medications frequently have to be administered and charted in the CIS Medication Administration Record (MAR) before pharmacists can enter them into the Pharmacy system. When the Pharmacy system belatedly sends medication orders to the CIS MAR, this may create duplicate entries for medications that ICU nurses have had to enter manually to chart doses actually given. The authors have implemented a real time interface between a Computerized Physician Order Entry (CPOE) system and a CIS operating in ten ICUs that solves this problem. The interface transfers new medication orders including order details and alerts directly to the CIS Medication Administration Record (MAR), where they are immediately available for nurse charting. METHODS: The Patient Care Expert (PCX) web-based CPOE system was developed at Cedars-Sinai Medical Center and interfaced to a CIS serving 133 beds in 10 ICUs (CareVue CIS, Philips Medical Systems, Andover, MA). The CPOE used an existing CIS interface specification available for Pharmacy systems. At other CIS sites Pharmacy interfaces had enjoyed limited success because in many cases, ICU nurses had to manually add drugs to the MAR to chart urgent and emergent doses. When physician orders were finally processed by the Pharmacy, the orders sent to the CIS were frequently posted on the MAR as duplicate entries, causing confusion in the medical record. Although the PCX CPOE was interfaced to the hospital's Pharmacy system, for ICU patients all medication orders were transmitted to the CIS MAR. As soon as a physician authenticated orders with an electronic signature (Figure 1), all medication orders appeared in the CIS MAR, ready for the nurse to verify the orders and then chart doses. The medications shown in gray in Figure 2 are new automatic entries the nurse will authenticate with an electronic signature. Once authenticated, nurses may chart individual doses Results: 40,170 ICU medication, IV infusion and IV drip orders were automatically transferred from the CPOE to ICU CIS MARs during three months of CPOE operation. The interface eliminated manual order transcription, medication entry errors and improved ICU nurse efficiency and satisfaction. (+info)