John B. Chessare

Effect of Computer Order Entry on Prevention of Serious Medication Errors in Hospitalized Children

OBJECTIVE. Although initial research suggests that computerized physician order entry reduces pediatric medication errors, no comprehensive error surveillance studies have evaluated the effect of computerized physician order entry on children. Our objective was to evaluate comprehensively the effect of computerized physician order entry on the rate of inpatient pediatric medication errors. METHODS. Using interrupted time-series regression analysis, we reviewed all charts, orders, and incident reports for 40 admissions per month to the NICU, PICU, and inpatient pediatric wards for 7 months before and 9 months after implementation of commercial computerized physician order entry in a general hospital. Nurse data extractors, who were unaware of study objectives, used an established error surveillance method to detect possible errors. Two physicians who were unaware of when the possible error occurred rated each possible error. RESULTS. In 627 pediatric admissions, with 12 672 medication orders written over 3234 patient-days, 156 medication errors were detected, including 70 nonintercepted serious medication errors (22/1000 patient-days). Twenty-three errors resulted in patient injury (7/1000 patient-days). In time-series analysis, there was a 7% decrease in level of the rates of nonintercepted serious medication errors. There was no change in the rate of injuries as a result of error after computerized physician order entry implementation. CONCLUSIONS. The rate of nonintercepted serious medication errors in this pediatric population was reduced by 7% after the introduction of a commercial computerized physician order entry system, much less than previously reported for adults, and there was no change in the rate of injuries as a result of error. Several human-machine interface problems, particularly surrounding selection and dosing of pediatric medications, were identified. Additional refinements could lead to greater effects on error rates.

Medication errors related to computerized order entry for children

OBJECTIVE. The objective of this study was to determine the frequency and types of pediatric medication errors attributable to design features of a computerized order entry system. METHODS. A total of 352 randomly selected, inpatient, pediatric admissions were reviewed retrospectively for identification of medication errors, 3 to 12 months after implementation of computerized order entry. Errors were identified and classified by using an established, comprehensive, active surveillance method. Errors attributable to the computer system were classified according to type. RESULTS. Among 6916 medication orders in 1930 patient-days, there were 104 pediatric medication errors, of which 71 were serious (37 serious medication errors per 1000 patient-days). Of all pediatric medication errors detected, 19% (7 serious and 13 with little potential for harm) were computer related. The rate of computer-related pediatric errors was 10 errors per 1000 patient-days, and the rate of serious computer-related pediatric errors was 3.6 errors per 1000 patient-days. The following 4 types of computer-related errors were identified: duplicate medication orders (same medication ordered twice in different concentrations of syrup, to work around computer constraints; 2 errors), drop-down menu selection errors (wrong selection from a drop-down box; 9 errors), keypad entry error (5 typed instead of 50; 1 error), and order set errors (orders selected from a pediatric order set that were not appropriate for the patient; 8 errors). In addition, 4 preventable adverse drug events in drug ordering occurred that were not considered computer-related but were not prevented by the computerized physician order entry system. CONCLUSIONS. Serious pediatric computer-related errors are uncommon (3.6 errors per 1000 patient-days), but computer systems can introduce some new pediatric medication errors that are not typically seen in a paper ordering system.

Changing physician behaviour

Changing physician behaviour has become an important focus of medicine over the past two decades.1-3 The rapid expansion of medical knowledge and concerns about quality of care, have led to the birth of both the practice guideline movement4 5 and evidence based medicine.6 7More recently, medical informatics and patient participation in care have matured as distinct clinical and research entities.8-11 Great Britain has recognised the importance of improving the quality of health care with the creation of the National Institute of Clinical Excellence and the Commission for Health Improvement.2 Ultimately, each of these developments hopes to influence physician behaviour and affect how physicians make decisions on behalf of patients. Rather than a traditional review of a medical topic, we have chosen to focus on a few selected issues that are critical if we are to understand how to change physician behaviour. This paper has four parts. Firstly, we briefly review issues related to quality of care to set a context for the need to change physician decision making as a key step to improvements in quality. Secondly, we present a contemporary view of how physicians make decisions. Thirdly, we summarise what is known about changing physician behaviour. Finally, we conclude with our own views about the topic. Our focus is on ambulatory care rather than inpatient services, although many of our comments are relevant to decision making in either environment. Our understanding of the dimensions of quality of paediatric care has grown substantially in recent years.12 13 There are individual, institutional, and regional variations in diagnostic testing, hospitalisation rates, therapeutic interventions, and outcomes.3 For example, data from the United States indicate that the care of some children with asthma is not consistent with the guidelines from the National Institutes of Health. Approximately …

Compliance with a prescription for psychotherapeutic counseling in childhood.

Pediatricians frequently refer children and their families for psychetherapeutic counseling. In order to maximize compliance with such a prescription, the physician should be aware of factors associated with noncompliance. We conducted a systematic retrospective analysis of factors associated with following a recommendation for counseling. We reviewed the records of 35 children who had been referred for counseling. One to two years after the recommendation was made, we asked their parents whether or not they had accessed these services. Compliant and noncompliant families were compared on a number of demographic, historical, and diagnostic parameters. No statistically significant association with the compliance factor was found. Only 53% of children had received the prescribed therapy. We conclude that noncompliance with a recommendation for psychotherapeutic counseling is a problem of significant proportion. Further work with a larger sample size will be needed to elucidate factors associated with noncompliance.

Milliman and Robertson-going in the wrong direction.

The Milliman and Robertson guide has created a great deal of consternation among pediatricians, particularly the sections that address optimal length of stay for common pediatric conditions. In his accompanying commentary,1 Dr Yetman introduces the new version of the Pediatric Health Status Improvement and Management 2 and carefully enumerates its strengths. Although management guidelines play an important role in medicine, we believe that there are a number of important limitations that must be recognized in this revision. Before authoring this commentary, we carefully reviewed the entire Milliman and Robertson document, noting both its strengths and weaknesses. Our comments reflect our review, discussions with pediatricians, and our clinical experience with how the Milliman and Robertson recommendations are often applied. It should be noted that in the introduction to each section, the authors carefully allude to the importance of individual patient and practitioner decision-making. Although the sections on subspecialty pediatrics, anticipatory guidance, and outpatient guidelines (their term) are well done; from a practical standpoint, the sections on inpatient guidelines and neonatology (including optimal length of stay) garner the most attention, especially when these sections are used … Address correspondence to Howard Bauchner, MD, Boston Medical Center/Maternity 4210, 91 E Concord St, Boston, MA 02118. E-mail:bauchner{at}bu.edu

Multidisciplinary Team Evaluation of School Dysfunction

Little is known of the characteristics of children experiencing school dysfunction who are evaluated by multidisciplinary teams. The records of 87 children seen during a calendar year were reviewed and information was gathered regarding their age, sex, and referral source. In addition, the chief concerns of the childs parents and educators, and the diagnostic outcome, were considered. Boys were more likely to have been referred for behavioral problems than for academic issues. Girls were seen at an earlier age. Younger children were more likely to have been referred by physicians. While there was a significant association between gender and reason for referral, we found no such relationship between gender and final diagnostic classification. Variables in the utilization of evaluation services are described. Cognizance of these issues should lead to improved provision of care to all children experiencing school dysfunction.

572 WHICH ELEMENTS OF PRENATAL SOCIAL SUPPORT IMPROVE NEONATAL MORBIDITY

Though prenatal psychosocial factors influence pregnancy outcome, the specific components of prenatal social support which improve neonatal morbidity have not been delineated. To define those elements of social support which alter neonatal morbidity, we studied 201 mothers seen consecutively by a social worker in a community hospital based obstetrical clinic. About 80% were receiving welfare and 20% had ]ow paying jobs. We assessed the availability of help with daily tasks, a communicative male and other adults, emergency child care as well as community involvement. Factor analysis generated a factor consisting of help with daily tasks and a communicative male support figure. The median of the combined score for these two items was used to divide the sample into “low” and “high” social support subgroups.About 20% (14/73) of infants from low support multigravida mothers were admitted to an NICU compared to 6% (4/66) of babies born to high support multigravida mothers (risk ratio=3.18, p=0.02) These differences were not present in primigravida mothers. Compared to infants of high support multigravida mothers, infants of low support mothers were smaller (3402±60gm vs. 3114±79gm, p=.005; 51.8±.34cm vs. 49.8±.49cm, p=.001) and born earlier(39.4±.17 weeks vs. 38.6±.29 weeks, p=.02). There were no differences between low and hip support multigravida mothers age, education, income or race. (p>0.2). These data suggest that providing prenatal help with daily tasks and a communicative male support figure may improve neonatal morbidity for infants of indigent, urban multigravida mothers.