Kathleen E. Walsh

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 Among Adults and Children With Cancer in the Outpatient Setting

PURPOSE Outpatients with cancer receive complicated medication regimens in the clinic and home. Medication errors in this setting are not well described. We aimed to determine rates and types of medication errors and systems factors associated with error in outpatients with cancer. METHODS We retrospectively reviewed records from visits to three adult and one pediatric oncology clinic in the Southeast, Southwest, Northeast, and Northwest for medication errors using established methods. Two physicians independently judged whether an error occurred (kappa = 0.65), identified its severity (kappa = 0.76), and listed possible interventions. RESULTS Of 1,262 adult patient visits involving 10,995 medications, 7.1% (n = 90; 95% CI, 5.7% to 8.6%) were associated with a medication error. Of 117 pediatric visits involving 913 medications, 18.8% (n = 22; 95% CI, 12.5% to 26.9%) were associated with a medication error. Among all visits, 64 of the 112 errors had the potential to cause harm, and 15 errors resulted in injury. There was a range in the rates of chemotherapy errors (0.3 to 5.8 per 100 visits) and home medication errors (0 to 14.5 per 100 visits in children) at different sites. Errors most commonly occurred in administration (56%). Administration errors were often due to confusion over two sets of orders, one written at diagnosis and another adjusted dose on the day of administration. Physician reviewers selected improved communication most often to prevent error. CONCLUSION Medication error rates are high among adult and pediatric outpatients with cancer. Our findings suggest some practical targets for intervention, including improved communication about medication administration in the clinic and home.

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.

Retrospective Evaluation of a Computerized Physician Order Entry Adaptation to Prevent Prescribing Errors in a Pediatric Emergency Department

OBJECTIVE. The goal was to determine the impact on medication prescribing errors of adding a pediatric medication list (quicklist) to a computerized physician order entry system in a pediatric emergency department. METHODS. The quicklist is a drug dosing support tool that targets the most common medications in our clinical setting. We performed a retrospective comparison of orders from 420 randomly selected visits before and after quicklist introduction. Error rates were analyzed with respect to urgency level, physician training level, and patient age. The quicklist was examined for frequency of use and error rates. RESULTS. The 840 patient visits (420 before intervention and 420 after intervention) generated 724 medication orders, which contained 156 medication prescribing errors (21%). The groups did not differ with respect to urgency level, physician training level, or patient age. There were significant decreases in the rate of errors per 100 visits, from 24 to 13 errors per 100 visits, and in the rate of errors per 100 orders, from 31 to 14 errors per 100 orders. The decrease in the error rates did not vary according to urgency score, age group, or physician training level. The quicklist was used in 30% of the orders in the postintervention group. In this group, the error rate was 1.9 errors per 100 orders when the quicklist was used, compared with 18.3 errors per 100 orders when the list was not used. Errors of wrong formulation, allergy, drug-drug interaction, and rule violations were eliminated. CONCLUSION. The introduction of the quicklist was followed by a significant reduction in medication prescribing errors. A list with dosing support for commonly used pediatric medications may help adapt computerized physician order entry systems designed for adults to serve pediatric populations more effectively.

Medication errors in the home: a multisite study of children with cancer.

OBJECTIVE: As home medication use increases, medications previously managed by nurses are now managed by patients and their families. Our objective was to describe the types of errors occurring in the home medication management of children with cancer. METHODS: In a prospective observational study at 3 pediatric oncology clinics in the northeastern and southeastern United States, patients undergoing chemotherapy and their parents were recruited from November 2007 through April 2011. We reviewed medical records and checked prescription doses. A trained nurse visited the home, reviewed medication bottles, and observed administration. Two physicians independently made judgments regarding whether an error occurred and its severity. Overall rates of errors were weighted to account for clustering within sites. RESULTS: We reviewed 963 medications and observed 242 medication administrations in the homes of 92 patients. We found 72 medication errors. Four errors led to significant patient injury. An additional 40 errors had potential for injury: 2 were life-threatening, 13 were serious, and 25 were significant. Error rates varied between study sites (40–121 errors per 100 patients); the weighted overall rate was 70.2 errors per 100 patients (95% confidence interval [CI]: 58.9–81.6). The weighted rate of errors with injury was 3.6 (95% CI: 1.7–5.5) per 100 patients and with potential to injure the patient was 36.3 (95% CI: 29.3–43.3) per 100 patients. Nonchemotherapy medications were more often involved in an error than chemotherapy. CONCLUSIONS: Medication errors were common in this multisite study of outpatient pediatric cancer care. Rates of preventable medication-related injuries in this outpatient population were comparable or higher than those found in studies of hospitalized patients.

Medication adherence among pediatric patients with sickle cell disease: A systematic review

OBJECTIVES: Describe rates of adherence for sickle cell disease (SCD) medications, identify patient and medication characteristics associated with nonadherence, and determine the effect of nonadherence and moderate adherence (defined as taking 60%–80% of doses) on clinical outcomes. METHODS: In February 2012 we systematically searched 6 databases for peer-reviewed articles published after 1940. We identified articles evaluating medication adherence among patients <25 years old with SCD. Two authors reviewed each article to determine whether it should be included. Two authors extracted data, including medication studied, adherence measures used, rates of adherence, and barriers to adherence. RESULTS: Of 24 articles in the final review, 23 focused on 1 medication type: antibiotic prophylaxis (13 articles), iron chelation (5 articles), or hydroxyurea (5 articles). Adherence rates ranged from 16% to 89%; most reported moderate adherence. Medication factors contributed to adherence. For example, prophylactic antibiotic adherence was better with intramuscular than oral administration. Barriers included fear of side effects, incorrect dosing, and forgetting. Nonadherence was associated with more vaso-occlusive crises and hospitalizations. The limited data available on moderate adherence to iron chelation and hydroxyurea indicates some clinical benefit. CONCLUSIONS: Moderate adherence is typical among pediatric patients with SCD. Multicomponent interventions are needed to optimally deliver life-changing medications to these children and should include routine monitoring of adherence, support to prevent mistakes, and education to improve understanding of medication risks and benefits.

Medication errors in the homes of children with chronic conditions

Background Children with chronic conditions often have complex medication regimens, usually administered at home by their parents. Objective To describe the types of medication errors in the homes of children with chronic conditions. Methods Our home visit methods include direct observation of administration, medication review and prescription dose checking. Parents of children with sickle cell disease and seizure disorders taking daily medications were recruited from paediatric subspecialty clinics from November 2007 to April 2009. Potential errors were reviewed by two physicians who made judgements about whether an error had occurred or not, and its severity. Results On 52 home visits, the authors reviewed 280 medications and found 61 medication errors (95% CI 46 to 123), including 31 with a potential to injure the child and 9 which did injure the child. Injuries often occurred when parents failed to fill prescriptions or to change doses due to communication problems, leading to further testing or continued pain, inflammation, seizures, vitamin deficiencies or other injuries. Errors not previously reported in the literature included communication failures between two parents at home leading to administration errors and difficulty preparing the medication for administration. 95% of parents not using support tools (eg, alarms, reminders) for medication use at home had an error compared to 44% of those using supports (χ2=13.9, p=0.0002). Conclusions Home visits detected previously undescribed types of outpatient errors which were common among children with sickle cell disease and seizure disorders. These should be targeted in future intervention development.

Costs of Venous Thromboembolism, Catheter-Associated Urinary Tract Infection, and Pressure Ulcer

OBJECTIVE: To estimate differences in the length of stay (LOS) and costs for comparable pediatric patients with and without venous thromboembolism (VTE), catheter-associated urinary tract infection (CAUTI), and pressure ulcer (PU). METHODS: We identified at-risk children 1 to 17 years old with inpatient discharges in the Nationwide Inpatient Sample. We used a high dimensional propensity score matching method to adjust for case-mix at the patient level then estimated differences in the LOS and costs for comparable pediatric patients with and without VTE, CAUTI, and PU. RESULTS: Incidence rates were 32 (VTE), 130 (CAUTI), and 3 (PU) per 10 000 at-risk patient discharges. Patients with VTE had an increased 8.1 inpatient days (95% confidence interval [CI]: 3.9 to 12.3) and excess average costs of

Validation of anaphylaxis in the Food and Drug Administration's Mini-Sentinel

27 686 (95% CI:

Surgical Site Infection Reduction by the Solutions for Patient Safety Hospital Engagement Network.

11 137 to