Karen C. Nanji

Errors associated with outpatient computerized prescribing systems

OBJECTIVE To report the frequency, types, and causes of errors associated with outpatient computer-generated prescriptions, and to develop a framework to classify these errors to determine which strategies have greatest potential for preventing them. MATERIALS AND METHODS This is a retrospective cohort study of 3850 computer-generated prescriptions received by a commercial outpatient pharmacy chain across three states over 4 weeks in 2008. A clinician panel reviewed the prescriptions using a previously described method to identify and classify medication errors. Primary outcomes were the incidence of medication errors; potential adverse drug events, defined as errors with potential for harm; and rate of prescribing errors by error type and by prescribing system. RESULTS Of 3850 prescriptions, 452 (11.7%) contained 466 total errors, of which 163 (35.0%) were considered potential adverse drug events. Error rates varied by computerized prescribing system, from 5.1% to 37.5%. The most common error was omitted information (60.7% of all errors). DISCUSSION About one in 10 computer-generated prescriptions included at least one error, of which a third had potential for harm. This is consistent with the literature on manual handwritten prescription error rates. The number, type, and severity of errors varied by computerized prescribing system, suggesting that some systems may be better at preventing errors than others. CONCLUSIONS Implementing a computerized prescribing system without comprehensive functionality and processes in place to ensure meaningful system use does not decrease medication errors. The authors offer targeted recommendations on improving computerized prescribing systems to prevent errors.

Overrides of medication-related clinical decision support alerts in outpatients

BACKGROUND Electronic prescribing is increasingly used, in part because of government incentives for its use. Many of its benefits come from clinical decision support (CDS), but often too many alerts are displayed, resulting in alert fatigue. OBJECTIVE To characterize the override rates for medication-related CDS alerts in the outpatient setting, the reasons cited for overrides at the time of prescribing, and the appropriateness of overrides. METHODS We measured CDS alert override rates and the coded reasons for overrides cited by providers at the time of prescribing. Our primary outcome was the rate of CDS alert overrides; our secondary outcomes were the rate of overrides by alert type, reasons cited for overrides at the time of prescribing, and override appropriateness for a subset of 600 alert overrides. Through detailed chart reviews of alert override cases, and selective literature review, we developed appropriateness criteria for each alert type, which were modified iteratively as necessary until consensus was reached on all criteria. RESULTS We reviewed 157,483 CDS alerts (7.9% alert rate) on 2,004,069 medication orders during the study period. 82,889 (52.6%) of alerts were overridden. The most common alerts were duplicate drug (33.1%), patient allergy (16.8%), and drug-drug interactions (15.8%). The most likely alerts to be overridden were formulary substitutions (85.0%), age-based recommendations (79.0%), renal recommendations (78.0%), and patient allergies (77.4%). An average of 53% of overrides were classified as appropriate, and rates of appropriateness varied by alert type (p<0.0001) from 12% for renal recommendations to 92% for patient allergies. DISCUSSION About half of CDS alerts were overridden by providers and about half of the overrides were classified as appropriate, but the likelihood of overriding an alert varied widely by alert type. Refinement of these alerts has the potential to improve the relevance of alerts and reduce alert fatigue.

Overcoming Barriers to the Implementation of a Pharmacy Bar Code Scanning System for Medication Dispensing: A Case Study

Technology has great potential to reduce medication errors in hospitals. This case report describes barriers to, and facilitators of, the implementation of a pharmacy bar code scanning system to reduce medication dispensing errors at a large academic medical center. Ten pharmacy staff were interviewed about their experiences during the implementation. Interview notes were iteratively reviewed to identify common themes. The authors identified three main barriers to pharmacy bar code scanning system implementation: process (training requirements and process flow issues), technology (hardware, software, and the role of vendors), and resistance (communication issues, changing roles, and negative perceptions about technology). The authors also identified strategies to overcome these barriers. Adequate training, continuous improvement, and adaptation of workflow to address ones own needs mitigated process barriers. Ongoing vendor involvement, acknowledgment of technology limitations, and attempts to address them were crucial in overcoming technology barriers. Staff resistance was addressed through clear communication, identifying champions, emphasizing new information provided by the system, and facilitating collaboration.

Are We Heeding the Warning Signs? Examining Providers’ Overrides of Computerized Drug-Drug Interaction Alerts in Primary Care

Background Health IT can play a major role in improving patient safety. Computerized physician order entry with decision support can alert providers to potential prescribing errors. However, too many alerts can result in providers ignoring and overriding clinically important ones. Objective To evaluate the appropriateness of providers’ drug-drug interaction (DDI) alert overrides, the reasons why they chose to override these alerts, and what actions they took as a consequence of the alert. Design A cross-sectional, observational study of DDI alerts generated over a three-year period between January 1st, 2009, and December 31st, 2011. Setting Primary care practices affiliated with two Harvard teaching hospitals. The DDI alerts were screened to minimize the number of clinically unimportant warnings. Participants A total of 24,849 DDI alerts were generated in the study period, with 40% accepted. The top 62 providers with the highest override rate were identified and eight overrides randomly selected for each (a total of 496 alert overrides for 438 patients, 3.3% of the sample). Results Overall, 68.2% (338/496) of the DDI alert overrides were considered appropriate. Among inappropriate overrides, the therapeutic combinations put patients at increased risk of several specific conditions including: serotonin syndrome (21.5%, n=34), cardiotoxicity (16.5%, n=26), or sharp falls in blood pressure or significant hypotension (28.5%, n=45). A small number of drugs and DDIs accounted for a disproportionate share of alert overrides. Of the 121 appropriate alert overrides where the provider indicated they would “monitor as recommended”, a detailed chart review revealed that only 35.5% (n=43) actually did. Providers sometimes reported that patients had already taken interacting medications together (15.7%, n=78), despite no evidence to confirm this. Conclusions and Relevance We found that providers continue to override important and useful alerts that are likely to cause serious patient injuries, even when relatively few false positive alerts are displayed.

Unrealized potential and residual consequences of electronic prescribing on pharmacy workflow in the outpatient pharmacy

INTRODUCTION Electronic prescribing systems have often been promoted as a tool for reducing medication errors and adverse drug events. Recent evidence has revealed that adoption of electronic prescribing systems can lead to unintended consequences such as the introduction of new errors. The purpose of this study is to identify and characterize the unrealized potential and residual consequences of electronic prescribing on pharmacy workflow in an outpatient pharmacy. METHODS A multidisciplinary team conducted direct observations of workflow in an independent pharmacy and semi-structured interviews with pharmacy staff members about their perceptions of the unrealized potential and residual consequences of electronic prescribing systems. We used qualitative methods to iteratively analyze text data using a grounded theory approach, and derive a list of major themes and subthemes related to the unrealized potential and residual consequences of electronic prescribing. RESULTS We identified the following five themes: Communication, workflow disruption, cost, technology, and opportunity for new errors. These contained 26 unique subthemes representing different facets of our observations and the pharmacy staffs perceptions of the unrealized potential and residual consequences of electronic prescribing. DISCUSSION We offer targeted solutions to improve electronic prescribing systems by addressing the unrealized potential and residual consequences that we identified. These recommendations may be applied not only to improve staff perceptions of electronic prescribing systems but also to improve the design and/or selection of these systems in order to optimize communication and workflow within pharmacies while minimizing both cost and the potential for the introduction of new errors.

It is time to use checklists for anesthesia emergencies: simulation is the vehicle for testing and learning.

T he use of simulation to improve medical training and patient safety has been growing in popularity. Many fully functional health care simulation centers now operate in the United States and throughout the world. Simulation is widely viewed as an important tool for a broad spectrum of education, training, and patient safety applications and particularly for the teaching and study of rare crisis events. However, simulation can also be used to evaluate new patient safety interventions, such as checklists. Many industries, such as the airline industry, manufacturing, food inspection, and pharmaceutical industries, have been using checklists for decades, especially as processes become more complex and the number of routine tasks required exceeds what can realistically be remembered, even by experts. Unfortunately, the health care industry has been a late adopter of checklists despite the complex and unpredictable situations often faced in the field. Checklists were initially introduced in anesthesia in the 1980s, although it took more than 10 years for checklists to be introduced in other clinical care areas. In a relatively short time, the reduction in process variability provided by checklists has led to improved outcomes and reduced incidence of central line infections, ventilator management, and end of life care. Despite improved patient outcomes resulting from using checklists in general, there is much more to learn about how to develop them, how to use them, and how to train clinicians to use them effectively for managing emergencies. In the case of rare clinical emergencies, such as local anesthesia systemic toxicity (LAST), it is likely impossible to become proficient with the use of checklists in an actual clinical setting. Simulation is the obvious vehicle for training. We see an excellent example of that in a study by Neal et al in this issue of Regional Anesthesia and Pain Medicine. Their study evaluated the use of the American Society of Regional Anesthesia’s (ASRA’s) checklist for managing LAST to improve trainees’ technical and nontechnical performance during a simulated LAST crisis event. We learn from this report that there is still much work required to optimize the use of checklists, in anesthesia and elsewhere, and to educate and train practitioners so that checklists are accepted as the cultural norm. Neal et al have demonstrated the usefulness of simulation for this purpose. The authors randomized trainees who were managing a simulated LAST crisis to either receive the checklist to use during the simulation or not to receive the checklist. They found that trainees who were given the checklist as an aid completed substantially more medical management tasks correctly than those who did not have the checklist. Furthermore, the checklist subjects scored higher in their overall crises management behaviors. These findings are consistent with a very recent study that shows improved adherence to critical management steps with the use of checklists during simulated crisis situations in the operating room. Neal et al illustrate that checklists can improve performance in the management of LAST. Without the checklist, performance was surprisingly poor; on average, the nonchecklist group completed only 8 of 21 essential tasks for management of a LAST crisis. Yet, even with the checklist, performance was not ideal; the checklist group, on average, performed only 16 of 21 essential tasks. Further deliberate practice, ideally with the use of simulation, is clearly required to improve performance. Perhaps a more striking finding in this study is that unless it was not reported, none of the 13 trainees in the nonchecklist group asked for a checklist. Each trainee had received the ASRA practice advisory 4 weeks before the study commenced, albeit ‘‘without fanfare.’’ Furthermore, a EDITORIAL

The effect of an olfactory and visual cue on realism and engagement in a health care simulation experience.

Introduction Fidelity has been identified as an important element in a subject’s perception of realism and engagement in learning during a simulation experience. The purpose of this study was to determine whether an isolated visual and olfactory sensory change to the simulation environment affects the subjects’ perceptions of realism during simulation cases. Methods Using an electrosurgical unit applied to bovine muscle tissue, we created a model to simulate the characteristic operating room smoke and burning odor that occur during many procedures. Anesthesiologist subjects were randomly assigned to an intervention group that participated in a simulation involving the characteristic smoke and odor or a control group whose simulation involved no smoke or odor. Subjects completed a 7-question survey on the fidelity of the simulation, their perception of realism, and their learning engagement. Results We enrolled 103 subjects over 22 simulation courses in our study (intervention, n = 52; control, n = 51). The subjects’ reactions to the physical (P = 0.73), conceptual (P = 0.34), and emotional (P = 0.12) fidelity and their perception of realism (P = 0.71) did not differ between the intervention and control groups. Discussion In a high-fidelity simulation environment, a visual and olfactory increment to physical fidelity did not affect subjects’ overall ratings of fidelity, perceptions of realism, and engagement in the learning experience.

Overarching goals: a strategy for improving healthcare quality and safety?

The management literature reveals that many successful organisations have strategic plans that include a bold ‘stretch-goal’ to stimulate progress over a ten-to-thirty-year period. A stretch goal is clear, compelling and easily understood. It serves as a unifying focal point for organisational efforts. The ambitiousness of such goals has been emphasised with the phrase Big Hairy Audacious Goal (‘BHAG’). President Kennedys proclamation in 1961 that ‘this Nation should commit itself to achieving the goal, before this decade is out, of landing a man on the moon and returning him safely to earth’ provides a famous example. This goal energised the US National Aeronautics and Space Administration, and it captured the attention of the American public and resulted in one of the largest accomplishments of any organisation. The goal set by Sony, a small, cash-strapped electronics company in the 1950s, to change the poor image of Japanese products around the world represents a classic BHAG. Few examples of quality goals that conform to the BHAG definition exist in the healthcare literature. However, the concept may provide a useful framework for organisations seeking to transform the quality of care they deliver. This review examines the merits and cautions of setting overarching quality goals to catalyse quality improvement efforts, and assists healthcare organisations with determining whether to adopt these goals.

A cross-sectional observational study of high override rates of drug allergy alerts in inpatient and outpatient settings, and opportunities for improvement

Objectives To evaluate how often and why providers overrode drug allergy alerts in both the inpatient and outpatient settings. Design A cross-sectional observational study of drug allergy alerts generated over a 3-year period between 1 January 2009 and 31 December 2011. Setting A 793-bed tertiary care teaching affiliate of Harvard Medical School and 36 primary care practices. Participants Drug allergy alerts were displayed for a total of 29 420 patients across both settings. Main outcome measures Proportion of drug allergy alerts displayed and overridden, proportion of appropriate overrides, proportion of overrides in each medication class, different reasons for overriding and types of reactions overridden. Results A total of 158 023 drug allergy alerts were displayed, 131 615 (83%) in the inpatient setting and 26 408 (17%) in the outpatient setting; 128 157 (81%) of which were overridden. A random sample of inpatient (n=200, 0.19%) and outpatient (n=50, 0.25%) alert overrides were screened for appropriateness, with >96% considered appropriate. Alerts for some drug classes, such as ‘non-antibiotic sulfonamides’, were overridden for >81% of prescriptions in both settings. The most common override reason was patient has taken previously without allergic reaction. In the inpatient setting alone, 70.9% of alerts that warned against the risk of anaphylaxis were overridden. Conclusions The information contained in patients’ drug allergy lists needs to be regularly updated. Most of the drug allergy alerts were overridden, with the majority of alert overrides in the subsample considered appropriate. Some of the rules for these alerts should be carefully reviewed and modified, or removed. Further research is needed to understand providers’ overriding of alerts that warned against the risk of ‘anaphylaxis’, which are more concerning with respect to patient safety.

Total Intravenous Anesthesia Using N-Methyl-D-Aspartate (NMDA) Receptor-Sparing Drugs in a Patient with Anti-NMDA Receptor Encephalitis.

Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is a recently identified syndrome characterized by psychosis and dysautonomia. Treatment includes resection of the underlying tumor. While the pathologic mechanism involves disruption of NMDA function by anti-NMDA receptor autoantibodies, there are few descriptions of the perioperative management or anesthetic approach for such patients. We report a classic presentation of anti-NMDA receptor encephalitis and describe the use of total IV anesthesia with NMDA receptor-sparing drugs. Modest postoperative analgesic requirements, not reported in prior cases, are also described in our report.