Some computerized physician order entry systems are limited, study shows
Adverse drug events still were high in the decision-support area
Researchers examining adverse drug events (ADEs) at a Veterans Affairs (VA) Hospital in Salt Lake City found surprising results. The computerized physician order entry (CPOE) system had reduced ADEs in some areas, but the rates were higher than expected in decision support. The results were published in the May 23 issue of the Archives of Internal Medicine.
The VA’s CPOE system had been implemented in phases on the hospital units between 1998 and the early part of 2000, says Jennifer M. Hoffman, PharmD, a health science specialist at the VA and one of the researchers. Their system checked for allergies, many drug-drug interactions, and limited drug-disease interactions. However, it did not offer drug selection, dosing, or monitoring advice. Bar code medication administration also was active in most units and covered 81% of the study patient-days.
The researchers originally wanted to find a baseline ADE count for all hospitals so they could do an intervention and determine afterward if they had decreased the number of ADEs in the clinical setting. "It turns out that none of the literature agrees on how many ADEs there are at any hospital," she says.
Instead the researchers decided to figure out their own baseline and where the intervention would best fit. For the study, Hoffman and another pharmacist classified inpatient ADEs from prospective daily reviews of electronic medical records from a random sample of all admissions during a 20-week period at the hospital in late 2000. The ADEs that were analyzed required a change in treatment plan.
The ADEs were more and different than Hoffman had expected. "A lot of studies have been out with a whole range of ADE incidents in all sorts of settings," she says. "What we had previously seen in the literature was different than [our findings], not just the numbers but the places they were occurring in the hospital, [too].
Among 937 hospital admissions, 483 clinically significant inpatient ADEs were identified. One quarter of the hospitalizations had at least one ADE. Of all ADEs, 9% resulted in serious harm, 22% in additional monitoring and interventions, 32% in interventions alone, and 11% in monitoring alone; 27% should have resulted in additional interventions or monitoring. Medication errors contributed to 27% of these ADEs. Errors associated with ADEs occurred in the following stages: 61% ordering, 25% monitoring, 13% administration, 1% dispensing, and 0% transcription. The medical record reflected recognition of 76% of the ADEs.
The researchers did note, however, that the higher number of ADEs found was likely facilitated by legible and accessible electronic data, iterative case review, and use of clinical pharmacists.
"The computerized system that we have is fantastic for what it is designed to do," Hoffman says. For example, no transcription errors were found. However, the system did not have decision-support functions, resulting in more errors found in these areas.
The study findings imply that purchasers of CPOE systems should not rely on generic CPOE and bar code medication administration systems alone to dramatically reduce ADE rates, the researchers say. "Rather, health care organizations desirous of preventing ADEs should consider whether candidate computerized medication systems offer decision support functions that address the most troublesome aspects of the medication administration process."
This study took place almost five years ago. The VA is making strides in adding decision-support functions to its system, Hoffman says, and has been commended for its use of health information technology to improve quality of care. The problem has been that such a system is difficult to design because it needs to be patient-specific. "We are moving in that direction."
In the meantime, she says, pharmacists can remember that the most common errors the researchers found were in prophylaxis and monitoring. "In a clinical setting, I would look for those types of errors — the preventable adverse drug errors — and keep them in the back of your mind when you are on the floor."
Researchers examining adverse drug events (ADEs) at a Veterans Affairs (VA) Hospital in Salt Lake City found surprising results. The computerized physician order entry (CPOE) system had reduced ADEs in some areas, but the rates were higher than expected in decision support.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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