Publications by authors named "Sarah P Slight"

48 Publications

Support for Healthcare Professionals After Surgical Patient Safety Incidents: A Qualitative Descriptive Study in 5 Teaching Hospitals.

J Patient Saf 2021 Apr 13. Epub 2021 Apr 13.

From the *School of Pharmacy, Newcastle University, Newcastle upon Tyne, United Kingdom †Singleton Hospital ‡Swansea Medical School, Swansea University, Swansea, Wales §Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne ∥Department of Sociology, Durham University, Durham ¶Newcastle upon Tyne Hospitals, NHS Foundation Trust, Newcastle upon Tyne, United Kingdom.

Objective: Patient safety incidents can have a profound effect on healthcare professionals, with some experiencing emotional and psychological distress. This study explored the support medical and nonmedical operating room staff received after being involved in a surgical patient safety incident(s) in 5 UK teaching hospitals.

Methods: An invitation letter and information sheet were e-mailed to all medical and nonmedical operating room staff (N = 927) across the 5 sites. Semistructured interviews were arranged with a range of different healthcare professionals working in operating rooms across a wide variety of surgical specialities. Interviews were audio recorded, transcribed verbatim, and analyzed using an inductive thematic approach.

Results: We conducted 45 interviews with medical and nonmedical operating room staff, who emphasized the importance of receiving personalized support soon after the incident. Operating room staff described how the first "go to" people were their peers and reported feeling comforted when their peers empathized with their own experience(s). Other participants found it very difficult to seek support, perceiving it as a sign of weakness. Although family members played an important role in supporting second victims, some participants felt unable to discuss the incident with them, fearing that they might not understand.

Conclusions: There should be clear support structures in place for operating room staff who have been involved in surgical incidents. Health organizations need to offer timely support to frontline staff after these incidents. Senior clinicians should be proactive in offering support to junior colleagues and empathize with their own experiences, thus shifting the competitive culture to one of openness and support.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PTS.0000000000000844DOI Listing
April 2021

Preventing sepsis; how can artificial intelligence inform the clinical decision-making process? A systematic review.

Int J Med Inform 2021 Apr 10;150:104457. Epub 2021 Apr 10.

School of Pharmacy, Newcastle University, King George VI Building, Newcastle upon Tyne, NE1 7RU, UK. Electronic address:

Background And Objectives: Sepsis is a life-threatening condition that is associated with increased mortality. Artificial intelligence tools can inform clinical decision making by flagging patients at risk of developing infection and subsequent sepsis. This systematic review aims to identify the optimal set of predictors used to train machine learning algorithms to predict the likelihood of an infection and subsequent sepsis.

Methods: This systematic review was registered in PROSPERO database (CRD42020158685). We conducted a systematic literature review across 3 large databases: Medline, Cumulative Index of Nursing and Allied Health Literature, and Embase. Quantitative primary research studies that focused on sepsis prediction associated with bacterial infection in adults in all care settings were eligible for inclusion.

Results: Seventeen articles met our inclusion criteria. We identified 194 predictors that were used to train machine learning algorithms, with 13 predictors used on average across all included studies. The most prevalent predictors included age, gender, smoking, alcohol intake, heart rate, blood pressure, lactate level, cardiovascular disease, endocrine disease, cancer, chronic kidney disease (eGFR<60 mL/min), white blood cell count, liver dysfunction, surgical approach (open or minimally invasive), and pre-operative haematocrit < 30 %. All included studies used artificial intelligence techniques, with average sensitivity 75.7 ± 17.88, and average specificity 63.08 ± 22.01.

Conclusion: The type of predictors influenced the predictive power and predictive timeframe of the developed machine learning algorithm. Predicting the likelihood of sepsis through artificial intelligence can help concentrate finite resources to those patients who are most at risk. Future studies should focus on developing more sensitive and specific algorithms.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijmedinf.2021.104457DOI Listing
April 2021

Learning from safety incidents in high-reliability organizations: a systematic review of learning tools that could be adapted and used in healthcare.

Int J Qual Health Care 2021 Mar;33(1)

School of Pharmacy, Newcastle University, King George VI Building, Newcastle Upon Tyne, Tyne and Wear NE1 7RU, UK.

Objective: A high-reliability organization (HRO) is an organization that has sustained almost error-free performance, despite operating in hazardous conditions where the consequences of errors could be catastrophic. A number of tools and initiatives have been used within HROs to learn from safety incidents, some of which have the potential to be adapted and used in healthcare. We conducted a systematic review to identify any learning tools deemed to be effective that could be adapted and used by multidisciplinary teams in healthcare following a patient safety incident.

Methods: This review followed the Preferred Reporting Items for Systematic Reviews and MetaAnalyses for Protocols reporting guidelines and was registered with the PROSPERO (CRD42017071528). A search of databases was carried out in January 2021, from the date of their commencement. We conducted a search on electronic databases such as Web of Science, Science Direct, MEDLINE in Process Jan 1950-present, EMBASE Jan 1974-present, CINAHL 1982-present, PsycINFO 1967-present, Scopus and Google Scholar. We also searched the grey literature including reports from government agencies, relevant doctoral dissertations and conference proceedings. A customized data extraction form was used to capture pertinent information from included studies and Critical Appraisal Skills Programme tool to appraise on their quality.

Results: A total of 5921 articles were identified, with 964 duplicate articles removed and 4932 excluded at the title (4055), abstract (510) and full-text (367) stages. Twenty-five articles were included in the review. Learning tools identified included debriefing, simulation, crew resource management and reporting systems to disseminate safety messages. Debriefing involved deconstructing incidents using reflective questions, whilst simulation training involved asking staff to relive the event again by performing the task(s) in a role-play scenario. Crew resource management is a set of training procedures that focus on communication, leadership and decision-making. Sophisticated incident-reporting systems provide valuable information on hazards and were widely recommended as a way of disseminating key safety messages following safety incidents. These learning tools were found to have a positive impact on learning if conducted soon after the incident with efficient facilitation.

Conclusion: Healthcare organizations should find ways to adapt to the learning tools or initiatives used in HROs following safety incidents. It is challenging to recommend any specific one as all learning tools have shown considerable promise. However, the way these tools or initiatives are implemented is critical, and so further work is needed to explore how to successfully embed them into healthcare organizations so that everyone at every level of the organization embraces them.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/intqhc/mzab046DOI Listing
March 2021

Designing the Optimal Digital Health Intervention for Patients' Use Before and After Elective Orthopedic Surgery: Qualitative Study.

J Med Internet Res 2021 Mar 8;23(3):e25885. Epub 2021 Mar 8.

School of Pharmacy, Newcastle University, Newcastle upon Tyne, United Kingdom.

Background: Health behavior changes made by patients during the perioperative period can impact the outcomes and success of elective surgeries. However, there remains a limited understanding of how best to support patients during this time, particularly through the use of digital health interventions. Recognizing and understanding the potential unmet needs of elective orthopedic surgery patients is central to motivating healthier behavior change, improving recovery, and optimizing overall surgical success in the short and long term.

Objective: The aim of this study is to explore patient perspectives on technology features that would help support them to change their lifestyle behaviors during the pre- and postoperative periods, and that could potentially maintain long-term healthy lifestyles following recovery.

Methods: Semistructured interviews with pre- and postoperative elective orthopedic patients were conducted between May and June 2020 using telephone and video call-based software. Patient perspectives on the use of digital technologies to complement current surgical care and support with lifestyle behavior changes were discussed. Interviews were audio recorded and transcribed verbatim. Reflexive thematic analysis enabled the development of themes from the data, with QSR NVivo software (version 12) facilitating data management. Ethical approval was obtained from the National Health Service Health Research Authority.

Results: A total of 18 participants were interviewed. Four themes were developed from the data regarding the design and functionality of digital technologies to best support the perioperative journey. These center around an intervention's ability to incorporate interactive, user-centered features; direct a descriptive and structured recovery; enable customizable, patient-controlled settings; and deliver both general and specific surgical advice in a timely manner. Interventions that are initiated preoperatively and continued postoperatively were perceived as beneficial. Interventions designed with personalized milestones were found to better guide patients through a structured recovery. Individualized tailoring of preparatory and recovery information was desired by patients with previously high levels of physical activity before surgery. The use of personalized progression-based exercises further encouraged physical recovery; game-like rewards and incentives were regarded as motivational for making and sustaining health behavior change. In-built video calling and messaging features offered connectivity with peers and clinicians for supported care delivery.

Conclusions: Specific intervention design and functionality features can provide better, structured support for elective orthopedic patients across the entire surgical journey and beyond. This study provides much-needed evidence relating to the optimal design and timing of digital interventions for elective orthopedic surgical patients. Findings from this study suggest a desire for personalized perioperative care, in turn, supporting patients to make health behavior changes to optimize surgical success. These findings should be used to influence future co-design projects to enable the design and implementation of patient-focused, tailored, and targeted digital health technologies within modern health care settings.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2196/25885DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7985803PMC
March 2021

Digital Support for Patients Undergoing Bariatric Surgery: Narrative Review of the Roles and Challenges of Online Forums.

JMIR Perioper Med 2020 Jul 15;3(2):e17230. Epub 2020 Jul 15.

School of Pharmacy, Institute of Population Health Sciences, Newcastle University, Newcastle Upon Tyne, United Kingdom.

Background: The internet has become an important medium within health care, giving patients the opportunity to search for information, guidance, and support to manage their health and well-being needs. Online forums and internet-based platforms appear to have changed the way many patients undergoing bariatric surgery view and engage with their health, before and after weight loss surgery. Given that significant health improvements result from sustained weight loss, ensuring patient adherence to recommended preoperative and postoperative guidance is critical for bariatric surgery success. In a patient cohort with high information needs preoperatively, and notoriously high attrition rates postoperatively, online forums may present an underutilized method of support.

Objective: The aim of this study was to conduct a narrative review focusing on the developing roles that online forums can play for patients with bariatric conditions preoperatively and postoperatively.

Methods: A literature search was conducted in October-November 2019 across 5 electronic databases: Scopus, EMBASE, PsycINFO, CINAHL, and MEDLINE. Qualitative or mixed methods studies were included if they evaluated patients undergoing bariatric surgery (or bariatric surgery health care professionals) engaging with, using, or analyzing online discussion forums or social media platforms. Using thematic analysis, themes were developed from coding patterns within the data to identify the roles and challenges of online forums for patients undergoing bariatric surgery.

Results: A total of 8 studies were included in this review, with 5 themes emerging around (1) managing expectations of a new life; (2) decision making and signposting; (3) supporting information seeking; (4) facilitating connectedness: peer-to-peer social and emotional support; and (5) enabling accessibility and connectivity with health care professionals.

Conclusions: Online forums could offer one solution to improving postoperative success by supporting and motivating patients. Future research should consider how best to design and moderate online forums for maximal effectiveness and the sharing of accurate information. The surgical multidisciplinary team may consider recommendations of online peer-support networks to complement care for patients throughout their surgical journey.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2196/17230DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7709839PMC
July 2020

Medication errors and adverse drug events in a UK hospital during the optimisation of electronic prescriptions: a prospective observational study.

Lancet Digit Health 2019 12 1;1(8):e403-e412. Epub 2019 Nov 1.

The Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, UK.

Background: WHO's Third Global Patient Safety Challenge, Medication Without Harm, focused on reducing the substantial burden of iatrogenic harm associated with medications by 50% in the next 5 years. We aimed to assess whether the number and type of medication errors changed as an electronic prescribing system was optimised over time in a UK hospital.

Methods: We did a prospective observational study at a tertiary-care teaching hospital. Eight senior clinical pharmacists reviewed patients' records and collected data across four adult wards (renal, cardiology, general medical, and orthopaedic surgical) over a 2-year period (from Sept 29, 2014, to June 9, 2016). All medication errors and potential and actual adverse drug events were documented and the number of medication errors measured over the course of four time periods 7-10 weeks long. Pharmacists also recorded instances where the electronic prescribing system contributed to an error (system-related errors). A negative-binomial model and a Poisson model were used to identify factors related to medication error rates.

Findings: 5796 primary errors were recorded over the four time periods (period 1, 47 days [Sep 29-Dec 2, 2014]; period 2, 38 days [April 20-June 12, 2015, for the renal, medical, and surgical wards and April 20-June 15, 2015, for the cardiology ward]; period 3, 35 days [Sep 28-Nov 27, 2015] for the renal ward, 37 days [Sep 28-Nov 23, 2015] for the medical ward, and 40 days [Sep 28-Nov 20, 2015] for the cardiology and surgical wards; and period 4, 37 days [Feb 22-April 15, 2015] for the renal and medical wards and 39 days for the cardiology [April 13-June 7, 2015] and surgery [April 18-June 9, 2015] wards; unanticipated organisational factors prevented data collection on some days during each time period). There was no change in the rate of primary medication errors per admission over the observation periods: 1·53 medication errors in period 1, 1·44 medication errors in period 2, 1·70 medication errors in period 3, and 1·43 medication errors in period 4, per admission. By contrast, the overall rate of different types of medication errors decreased over the four periods. The most common types of error were medicine-reconciliation, dose, and avoidable delay-of-treatment errors. Some types of errors appeared to reduce over time (eg, dose errors [from 52 errors in period 1 to 19 errors in period 4, per 100 admissions]), whereas others increased (eg, inadequate follow-up of therapy [from 12 errors in period 1 to 24 errors in period 4, per 100 admissions]). We also found a reduction in the rates of potential adverse drug events between the first three periods and period 4. 436 system-related errors were recorded over the study period.

Interpretation: Although the overall rates of primary medication errors per admission did not change, we found a reduction in some error types and a significant decrease in the rates of potential adverse drug events over a 2-year period, during which system optimisation occurred. Targeting some error types could have the added benefit of reducing others, which suggests that system optimisation could ultimately help improve patient safety and outcomes.

Funding: No funding.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/S2589-7500(19)30158-XDOI Listing
December 2019

Relationship between labour force satisfaction, wages and retention within the UK National Health Service: a systematic review of the literature.

BMJ Open 2020 07 21;10(7):e034919. Epub 2020 Jul 21.

School of Pharmacy, Newcastle University, Newcastle upon Tyne, England, UK

Objectives: A systematic review was undertaken to understand the nature of the relationship between the UK National Health Service (NHS) labour force and satisfaction, retention and wages.

Design: Narrative systematic review.

Data Sources: The literature was searched using seven databases in January 2020: MEDLINE (1996-present), the Cumulative Index to Nursing and Allied Health Literature (CINAHL via EBSCO) (1984-present), Embase (1996-present), PsycINFO (1987-present), ProQuest (1996-present), Scopus (all years) and Cochrane library (all years). We used medical subject headings and key words relating to 'retention', 'satisfaction' and 'wages'.

Eligibility Criteria For Selecting Studies: Primary research studies or reviews that focused on the following relationships within the NHS workforce: wages and job satisfaction, job satisfaction and retention or wages and retention.

Data Extraction And Synthesis: Two independent reviewers screened all titles, abstracts and full texts, with arbitration by a third reviewer.

Results: 27 803 articles were identified and after removing duplicates (n=17 156), articles were removed at the title (n=10 421), abstract (n=150) and full-text (n=45) stages. A total of 31 full-text articles were included. They identified three broad themes, low job satisfaction impacting negatively on job retention, poor pay impacting negatively on staff satisfaction and the limitations of increasing pay as a means of improving staff retention. Several factors affected these relationships, including the environment, discrimination, flexibility, autonomy, training and staffing levels.

Conclusions: This review highlighted how multiple factors influence NHS labour force retention. Pay was found to influence satisfaction, which in turn affected retention. An increase in wages alone is unlikely to be sufficient to ameliorate the concerns of NHS workers. More research is needed to identify the role of autonomy on retention. A system leadership approach underpinned by data is required to implement bespoke job satisfaction improvement strategies to improve retention and achieve the goals of the NHS Long Term Plan.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjopen-2019-034919DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7375434PMC
July 2020

A systematic review of the impact of health information technology on nurses' time.

J Am Med Inform Assoc 2020 05;27(5):798-807

School of Pharmacy, Newcastle University, Newcastle upon Tyne, UK.

Objective: Nursing time represents one of the highest costs for most health services. We conducted a systematic review of the literature on the impact of health information technology on nurses' time.

Materials And Methods: We followed PRISMA guidelines and searched 6 large databases for relevant articles published between Jan 2004 and December 2019. Two authors reviewed the titles, abstracts, and full texts. We included articles that included a comparison group in the design, measured the time taken to carry out documentation or medication administration, documented the quantitative estimates of time differences between the 2, had nurses as subjects, and was conducted in either a care home, hospital, or community clinic.

Results: We identified a total of 1647 articles, of which 33 met our inclusion criteria. Twenty-one studies reported the impact of 12 different health information technology (HIT) implementations on nurses' documentation time. Weighted averages were calculated for studies that implemented barcode medication administration (BCMA) and 2 weighted averages for those that implemented EHRs, as these studies used different sampling units; both showed an increase in the time spent in documentation (+22% and +46%). However, the time spent carrying out medication administration following BCMA implementation fell by 33% (P < .05). HIT also caused a redistribution of nurses' time which, in some cases, was spent in more "value-adding" activities, such as delivering direct patient care as well as inter-professional communication.

Discussion And Conclusions: Most of the HIT systems increased nursing documentation time, although time fell for medication administration following BCMA. Many HIT systems also resulted in nurses spending more time in direct care and "value-adding" activities.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/jamia/ocz231DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7309250PMC
May 2020

Evaluation of Harm Associated with High Dose-Range Clinical Decision Support Overrides in the Intensive Care Unit.

Drug Saf 2019 04;42(4):573-579

The Center for Patient Safety Research and Practice, Brigham and Women's Hospital, Boston, MA, USA.

Introduction: Medication-related clinical decision support (CDS) alerts have been shown to be effective at reducing adverse drug events (ADEs). However, these alerts are frequently overridden, with limited data linking these overrides to harm. Dose-range checking alerts are a type of CDS alert that could have a significant impact on morbidity and mortality, especially in the intensive care unit (ICU) setting.

Methods: We performed a single-center, prospective, observational study of adult ICUs from September 2016 to April 2017. Targeted overridden alerts were triggered when doses greater than or equal to 5% over the maximum dose were prescribed. The primary outcome was the appropriateness of the override, determined by two independent reviewers, using pre-specified criteria formulated by a multidisciplinary group. Overrides which resulted in medication administration were then evaluated for ADEs by chart review.

Results: The override rate of high dose-range alerts in the ICU was 93.0% (total n = 1525) during the study period. A total of 1418 overridden alerts from 755 unique patients were evaluated for appropriateness (appropriateness rate 88.8%). The most common medication associated with high dose-range alerts was insulin regular infusion (n = 262, 18.5%). The rates of ADEs for the appropriately and inappropriately overridden alerts per 100 overridden alerts were 1.3 and 5.0, respectively (p < 0.001).

Conclusions: Overriding high dose-range CDS alerts was found to be common and often appropriate, suggesting that more intelligent dose checking is needed. Some alerts were clearly inappropriately presented to the provider. Inappropriate overrides were associated with an increased risk of ADEs, compared to appropriately overridden alerts.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s40264-018-0756-xDOI Listing
April 2019

The national cost of adverse drug events resulting from inappropriate medication-related alert overrides in the United States.

J Am Med Inform Assoc 2018 09;25(9):1183-1188

The Centre for Patient Safety Research and Practice, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.

Objective: To estimate the national cost of ADEs resulting from inappropriate medication-related alert overrides in the U.S. inpatient setting.

Materials And Methods: We used three different regression models (Basic, Model 1, Model 2) with model inputs taken from the medical literature. A random sample of 40 990 adult inpatients at the Brigham and Women's Hospital (BWH) in Boston with a total of 1 639 294 medication orders was taken. We extrapolated BWH medication orders using 2014 National Inpatient Sample (NIS) data.

Results: Using three regression models, we estimated that 29.7 million adult inpatient discharges in 2014 resulted in between 1.02 billion and 1.07 billion medication orders, which in turn generated between 75.1 million and 78.8 million medication alerts, respectively. Taking the basic model (78.8 million), we estimated that 5.5 million medication-related alerts might have been inappropriately overridden, resulting in approximately 196 600 ADEs nationally. This was projected to cost between $871 million and $1.8 billion for treating preventable ADEs. We also estimated that clinicians and pharmacists would have jointly spent 175 000 hours responding to 78.8 million alerts with an opportunity cost of $16.9 million.

Discussion And Conclusion: These data suggest that further optimization of hospitals computerized provider order entry systems and their associated clinical decision support is needed and would result in substantial savings. We have erred on the side of caution in developing this range, taking two conservative cost estimates for a preventable ADE that did not include malpractice or litigation costs, or costs of injuries to patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/jamia/ocy066DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7646874PMC
September 2018

Prospective evaluation of medication-related clinical decision support over-rides in the intensive care unit.

BMJ Qual Saf 2018 09 9;27(9):718-724. Epub 2018 Feb 9.

Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.

Background: Clinical decision support (CDS) displayed in electronic health records has been found to reduce the incidence of medication errors and adverse drug events (ADE). Recent data suggested that medication-related CDS alerts were frequently over-ridden, often inappropriately. Patients in the intensive care unit (ICU) are at an increased risk of ADEs; however, limited data exist on the benefits of CDS in the ICU. This study aims to evaluate potential harm associated with medication-related CDS over-rides in the ICU.

Methods: This was a prospective observational study of adults admitted to any of six ICUs between July 2016 and April 2017 at our institution. Patients with provider-overridden CDS for dose (orders for scheduled frequency and not pro re nata), drug allergy, drug-drug interaction, geriatric and renal alerts (contraindicated medications for renal function or renal dosing) were included. The primary outcome was the appropriateness of over-rides, which were evaluated by two independent reviewers. Secondary outcomes included incidence of ADEs following alert over-ride and risk of ADEs based on over-ride appropriateness.

Results: A total of 2448 over-ridden alerts from 712 unique patient encounters met inclusion criteria. The overall appropriateness rate for over-rides was 81.6% and varied by alert type. More ADEs (potential and definite) were identified following inappropriate over-rides compared with appropriate over-rides (16.5 vs 2.74 per 100 over-ridden alerts, Fisher's exact test P<0.001). An adjusted logistic regression model showed that inappropriate over-rides were associated with an increased risk of ADEs (OR 6.14, 95% CI 4.63 to 7.71, P<0.001).

Conclusions: Approximately four of five identified CDS over-rides were appropriately over-ridden, with the rate varying by alert type. However, inappropriate over-rides were six times as likely to be associated with potential and definite ADEs, compared with appropriate over-rides. Further efforts should be targeted at improving the positive predictive value of CDS such as by suppressing alerts that are appropriately over-ridden.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjqs-2017-007531DOI Listing
September 2018

Improving medication-related clinical decision support.

Am J Health Syst Pharm 2018 02;75(4):239-246

Center for Patient Safety Research and Practice, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA.

Purpose: Current uses of medication-related clinical decision support (CDS) and recommendations for improving these systems are reviewed.

Summary: Using a systematic approach, articles published from 2007 through 2014 were identified in MEDLINE and EMBASE using MeSH terms and keywords relating to the 5 basic medication-related CDS functionalities. A total of 156 full-text articles and 28 conference abstracts were reviewed across each of the 5 areas: drug-drug interaction (DDI) checks ( = 78), drug allergy checks ( = 20), drug dose support ( = 55), drug duplication checks ( = 11), and drug formulary support ( = 20). The success of medication-related CDS depends on users finding the alerts valuable and acting on the information received. Improving alert specificity and sensitivity is important for all domains. Tiering is important for improving the acceptance of DDI alerts. The ability to perform appropriate cross-sensitivity checks is key to producing appropriate drug allergy checks. Drug dosage alerts should be individualized and deliver practical recommendations. How the system is configured to identify certain drug duplications is important to prevent possible patient toxicity. Accurate knowledge databases are needed to produce relevant drug formulary alerts and encourage formulary adherence. Medication-related CDS is still relatively immature in some organizations and has substantial room for improvement. For example, decision support should consider more patient-specific factors, human factors principles should always be considered, and alert specificity must be improved in order to reduce alert fatigue.

Conclusion: Standardization, integration of patient-specific parameters, and consideration of human factors design principles are central to realizing the potential benefits of medication-related CDS.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2146/ajhp160830DOI Listing
February 2018

High-priority and low-priority drug-drug interactions in different international electronic health record systems: A comparative study.

Int J Med Inform 2018 03 9;111:165-171. Epub 2018 Jan 9.

The Centre for Patient Safety Research and Practice, Division of General Internal Medicine and Primary Care, Partners Healthcare, Boston, MA, USA; School of Pharmacy, Newcastle University, King George VI Building, Newcastle Upon Tyne, Queen Victoria Road, UK; Newcastle upon Tyne Hospitals NHS Foundation Trust, Queen Victoria Road, Newcastle, UK. Electronic address:

Objectives: To investigate whether alert warnings for high-priority and low-priority drug-drug interactions (DDIs) were present in five international electronic health record (EHR) systems, to compare and contrast the severity level assigned to them, and to establish the proportion of alerts that were overridden.

Methods: We conducted a comparative, retrospective, multinational study using a convenience sample of 5 EHRs from the U.S., U.K., Republic of Korea and Belgium.

Results: Of the 15 previously defined, high-priority, class-based DDIs, alert warnings were found to exist for 11 in both the Korean and UK systems, 9 in the Belgian system, and all 15 in the two US systems. The specific combinations that were included in these class-based DDIs varied considerably in number, type and level of severity amongst systems. Alerts were only active for 8.4% (52/619) and 52.4% (111/212) of the specific drug-drug combinations contained in the Belgian and UK systems, respectively. Hard stops (not possible to override) existed in the US and UK systems only. The override rates for high-priority alerts requiring provider action ranged from 56.7% to 83.3%. Of the 33 previously defined low-priority DDIs, active alerts existed only in the US systems, for three class-based DDIs. The majority were non-interruptive.

Conclusions: Alert warnings existed for most of the high-priority DDIs in the different EHRs but overriding them was easy in most of the systems. In addition to validating the high- and low-priority DDIs, this study reported a lack of standardization in DDI levels across different international knowledge bases.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijmedinf.2017.12.027DOI Listing
March 2018

Consensus methodology to determine minor ailments appropriate to be directed for management within community pharmacy.

Res Social Adm Pharm 2018 11 4;14(11):1027-1042. Epub 2018 Jan 4.

School of Pharmacy, Sir James Spence Institute Building, Newcastle University, Newcastle-upon-Tyne, UK.

Background: National Health Service (NHS) 111, a medical helpline for urgent care used within the England and Scotland, receives significant numbers of patient calls yearly for a range of clinical conditions. Some are considered high acuity and mainly directed to urgent and emergency care. Low acuity conditions are also directed to these costly, overburdened services. Community pharmacy is a recognised setting for effective low acuity condition management and could offer an alternative.

Objective: To design and evaluate a new NHS111 pathway re-directing patients with low acuity conditions to community pharmacy.

Methods: Two consensus development stakeholder workshops were undertaken. A "low acuity" condition was defined as one that can be clinically assessed by a community pharmacist and requires a treatment and/or advice available within a community pharmacy. Retrospective NHS111 patient data (February-August 2016) from the North East of England and access to the NHS Pathways clinical decision support software were available to stakeholders. The NHS111 data demonstrated the volume of patient calls for these conditions that could have been redirected to community pharmacy.

Results: Stakeholders reached consensus that 64 low acuity conditions could be safely redirected to community pharmacy via NHS111. This represented approximately 35,000 patients (11.5% of total) being shifted away from the higher cost settings in the North East region alone during February-August 2016. The stakeholder group discussions provided rationale behind their classifications of conditions to ensure patient safety, the care experience and added value.

Conclusions: The resulting definitive list of low acuity conditions that could be directed to community pharmacy via NHS111 could result in a shift of workload from urgent and emergency care settings. Future work needs to evaluate the cost, clinical outcomes, patient satisfaction of a community pharmacy referral service that has the potential to improve integration of community pharmacy in the wider NHS.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.sapharm.2018.01.001DOI Listing
November 2018

A value set for documenting adverse reactions in electronic health records.

J Am Med Inform Assoc 2018 06;25(6):661-669

Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.

Objective: To develop a comprehensive value set for documenting and encoding adverse reactions in the allergy module of an electronic health record.

Materials And Methods: We analyzed 2 471 004 adverse reactions stored in Partners Healthcare's Enterprise-wide Allergy Repository (PEAR) of 2.7 million patients. Using the Medical Text Extraction, Reasoning, and Mapping System, we processed both structured and free-text reaction entries and mapped them to Systematized Nomenclature of Medicine - Clinical Terms. We calculated the frequencies of reaction concepts, including rare, severe, and hypersensitivity reactions. We compared PEAR concepts to a Federal Health Information Modeling and Standards value set and University of Nebraska Medical Center data, and then created an integrated value set.

Results: We identified 787 reaction concepts in PEAR. Frequently reported reactions included: rash (14.0%), hives (8.2%), gastrointestinal irritation (5.5%), itching (3.2%), and anaphylaxis (2.5%). We identified an additional 320 concepts from Federal Health Information Modeling and Standards and the University of Nebraska Medical Center to resolve gaps due to missing and partial matches when comparing these external resources to PEAR. This yielded 1106 concepts in our final integrated value set. The presence of rare, severe, and hypersensitivity reactions was limited in both external datasets. Hypersensitivity reactions represented roughly 20% of the reactions within our data.

Discussion: We developed a value set for encoding adverse reactions using a large dataset from one health system, enriched by reactions from 2 large external resources. This integrated value set includes clinically important severe and hypersensitivity reactions.

Conclusion: This work contributes a value set, harmonized with existing data, to improve the consistency and accuracy of reaction documentation in electronic health records, providing the necessary building blocks for more intelligent clinical decision support for allergies and adverse reactions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/jamia/ocx139DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6251510PMC
June 2018

Evaluation of 'Definite' Anaphylaxis Drug Allergy Alert Overrides in Inpatient and Outpatient Settings.

Drug Saf 2018 03;41(3):297-302

Division of General Internal Medicine and Primary Care, The Center for Patient Safety Research and Practice, Brigham and Women's Hospital, 1620 Tremont Street, 75 Francis Street, Boston, MA, 02115, USA.

Introduction: Drug-allergy interaction (DAI) alerts are generated when a known adverse sensitivity-inducing substance is prescribed. A recent study at our institution showed that providers overrode most DAI alerts, including those that warned against potentially life-threatening 'anaphylaxis'.

Objective: The aim of this study was to determine the rate of anaphylaxis overrides, the reasons for these overrides, whether the overrides were appropriate, and if harm occurred from overrides.

Methods: All DAI alerts, with a reaction of 'anaphylaxis', were analysed for inpatients and outpatients within our health system between January 2009 and December 2011. Only alerts that were triggered by 'definite' alerts (i.e. same ordered medication as documented allergen) were included. Patient charts were reviewed to assess the appropriateness of overrides and potential harm, according to a predetermined set of criteria.

Results: A total of 202 inpatient and 16 outpatient alerts met the inclusion criteria. The rate of overrides for 'definite' anaphylaxis DAI alerts was high (inpatient: n = 93, 46.0%; outpatient: n = 11, 68.8%) but appropriate for most overrides in the inpatient (n = 78, 83.9%) and outpatient settings (n = 11, 100%). The most common override reasons in the inpatient and outpatient settings were 'administer per desensitization protocol' (n = 64, 31.7%) and 'patient does not have this allergy' (n = 7, 63.6%), respectively. No harm was associated with overrides in either setting, particularly because many medications were not administered.

Conclusions: Overrides of 'definite' anaphylaxis DAI alerts were common and often appropriate. Most overrides were due to desensitizations. Allergy reconciliation for patients could further improve critical decision support.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s40264-017-0615-1DOI Listing
March 2018

Medication-related clinical decision support alert overrides in inpatients.

J Am Med Inform Assoc 2018 05;25(5):476-481

Harvard Medical School, Boston, MA, USA.

Objective: To define the types and numbers of inpatient clinical decision support alerts, measure the frequency with which they are overridden, and describe providers' reasons for overriding them and the appropriateness of those reasons.

Materials And Methods: We conducted a cross-sectional study of medication-related clinical decision support alerts over a 3-year period at a 793-bed tertiary-care teaching institution. We measured the rate of alert overrides, the rate of overrides by alert type, the reasons cited for overrides, and the appropriateness of those reasons.

Results: Overall, 73.3% of patient allergy, drug-drug interaction, and duplicate drug alerts were overridden, though the rate of overrides varied by alert type (P < .0001). About 60% of overrides were appropriate, and that proportion also varied by alert type (P < .0001). Few overrides of renal- (2.2%) or age-based (26.4%) medication substitutions were appropriate, while most duplicate drug (98%), patient allergy (96.5%), and formulary substitution (82.5%) alerts were appropriate.

Discussion: Despite warnings of potential significant harm, certain categories of alert overrides were inappropriate >75% of the time. The vast majority of duplicate drug, patient allergy, and formulary substitution alerts were appropriate, suggesting that these categories of alerts might be good targets for refinement to reduce alert fatigue.

Conclusion: Almost three-quarters of alerts were overridden, and 40% of the overrides were not appropriate. Future research should optimize alert types and frequencies to increase their clinical relevance, reducing alert fatigue so that important alerts are not inappropriately overridden.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/jamia/ocx115DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7646870PMC
May 2018

Factors contributing to medication errors made when using computerized order entry in pediatrics: a systematic review.

J Am Med Inform Assoc 2018 05;25(5):575-584

School of Pharmacy, Newcastle University, Newcastle upon Tyne, UK.

Objective: To identify and understand the factors that contribute to medication errors associated with the use of computerized provider order entry (CPOE) in pediatrics and provide recommendations on how CPOE systems could be improved.

Materials And Methods: We conducted a systematic literature review across 3 large databases: the Cumulative Index to Nursing and Allied Health Literature, Embase, and Medline. Three independent reviewers screened the titles, and 2 authors then independently reviewed all abstracts and full texts, with 1 author acting as a constant across all publications. Data were extracted onto a customized data extraction sheet, and a narrative synthesis of all eligible studies was undertaken.

Results: A total of 47 articles were included in this review. We identified 5 factors that contributed to errors with the use of a CPOE system: (1) lack of drug dosing alerts, which failed to detect calculation errors; (2) generation of inappropriate dosing alerts, such as warnings based on incorrect drug indications; (3) inappropriate drug duplication alerts, as a result of the system failing to consider factors such as the route of administration; (4) dropdown menu selection errors; and (5) system design issues, such as a lack of suitable dosing options for a particular drug.

Discussion And Conclusions: This review highlights 5 key factors that contributed to the occurrence of CPOE-related medication errors in pediatrics. Dosing support is the most important. More advanced clinical decision support that can suggest doses based on the drug indication is needed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/jamia/ocx124DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7646858PMC
May 2018

Patients' evaluations of patient safety in English general practices: a cross-sectional study.

Br J Gen Pract 2017 Jul 5;67(660):e474-e482. Epub 2017 Jun 5.

Health Services and Policy Research Group, Patient Centred Care, University of Exeter Collaboration for Academic Primary Care (APEx), Exeter, UK.

Background: Description of safety problems and harm in general practices has previously relied on information from health professionals, with scarce attention paid to experiences of patients.

Aim: To examine patient-reported experiences and outcomes of patient safety in primary care.

Design And Setting: Cross-sectional study in 45 general practices across five regions in the north, centre, and south of England.

Method: A version of the Patient Reported Experiences and Outcomes of Safety in Primary Care (PREOS-PC) questionnaire was sent to a random sample of 6736 patients. Main outcome measures included 'practice activation' (what a practice does to create a safe environment); 'patient activation' (how proactive are patients in ensuring safe healthcare delivery); 'experiences of safety events' (safety errors); 'outcomes of safety' (harm); and 'overall perception of safety' (how safe patients rate their practice).

Results: Questionnaires were returned by 1244 patients (18.4%). Scores were high for 'practice activation' (mean [standard error] = 80.4 out of 100 [2.0]) and low for 'patient activation' (26.3 out of 100 [2.6]). Of the patients, 45% reported experiencing at least one safety problem in the previous 12 months, mostly related to appointments (33%), diagnosis (17%), patient provider communication (15%), and coordination between providers (14%). Twenty-three per cent of the responders reported some degree of harm in the previous 12 months. The overall assessment of level of safety of practices was generally high (86.0 out of 100 [16.8]).

Conclusion: Priority areas for patient safety improvement in general practices in England include appointments, diagnosis, communication, coordination, and patient activation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3399/bjgp17X691085DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5565856PMC
July 2017

Prevalence of food allergies and intolerances documented in electronic health records.

J Allergy Clin Immunol 2017 Dec 31;140(6):1587-1591.e1. Epub 2017 May 31.

Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass; Clinical Informatics, Partners eCare, Partners HealthCare System, Boston, Mass. Electronic address:

Background: Food allergy prevalence is reported to be increasing, but epidemiological data using patients' electronic health records (EHRs) remain sparse.

Objective: We sought to determine the prevalence of food allergy and intolerance documented in the EHR allergy module.

Methods: Using allergy data from a large health care organization's EHR between 2000 and 2013, we determined the prevalence of food allergy and intolerance by sex, racial/ethnic group, and allergen group. We examined the prevalence of reactions that were potentially IgE-mediated and anaphylactic. Data were validated using radioallergosorbent test and ImmunoCAP results, when available, for patients with reported peanut allergy.

Results: Among 2.7 million patients, we identified 97,482 patients (3.6%) with 1 or more food allergies or intolerances (mean, 1.4 ± 0.1). The prevalence of food allergy and intolerance was higher in females (4.2% vs 2.9%; P < .001) and Asians (4.3% vs 3.6%; P < .001). The most common food allergen groups were shellfish (0.9%), fruit or vegetable (0.7%), dairy (0.5%), and peanut (0.5%). Of the 103,659 identified reactions to foods, 48.1% were potentially IgE-mediated (affecting 50.8% of food allergy or intolerance patients) and 15.9% were anaphylactic. About 20% of patients with reported peanut allergy had a radioallergosorbent test/ImmunoCAP performed, of which 57.3% had an IgE level of grade 3 or higher.

Conclusions: Our findings are consistent with previously validated methods for studying food allergy, suggesting that the EHR's allergy module has the potential to be used for clinical and epidemiological research. The spectrum of severity observed with food allergy highlights the critical need for more allergy evaluations.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jaci.2017.04.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7059078PMC
December 2017

Evaluation of medication-related clinical decision support alert overrides in the intensive care unit.

J Crit Care 2017 06 20;39:156-161. Epub 2017 Feb 20.

The Center for Patient Safety Research and Practice, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA. Electronic address:

Purpose: Medication-related clinical decision support (CDS) has been identified as a method to improve patient outcomes but is historically frequently overridden and may be inappropriately so. Patients in the intensive care unit (ICU) are at a higher risk of harm from adverse drug events (ADEs) and these overrides may increase patient harm. The objective of this study is to determine appropriateness of overridden medication-related CDS overrides in the ICU.

Materials And Methods: We evaluated overridden medication-related alerts of four alert categories from January 2009 to December 2011. The primary outcome was the appropriateness of a random sample of overrides based on predetermined criteria. Secondary outcomes included the incidence of adverse drug events (ADEs) that resulted from the overridden alert.

Results: A total of 47,449 overridden alerts were included for evaluation. The appropriateness rate for overridden alerts varied by alert category (allergy: 94%, drug-drug interaction: 84%, geriatric: 57%, renal: 27%). A total of seven actual ADEs were identified in the random sample and where the medication(s) was administered (n=366), with an increased risk of ADEs associated with inappropriately overridden alerts (p=0.0078).

Conclusions: The appropriateness of medication-related clinical decision support overrides in the ICU varied substantially by the type of alert. Inappropriately overridden alerts were associated with an increased risk of ADEs compared to appropriately overridden alerts.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jcrc.2017.02.027DOI Listing
June 2017

Identifying patient-centred recommendations for improving patient safety in General Practices in England: a qualitative content analysis of free-text responses using the Patient Reported Experiences and Outcomes of Safety in Primary Care (PREOS-PC) questionnaire.

Health Expect 2017 10 28;20(5):961-972. Epub 2017 Feb 28.

Health Services and Policy Research Group, Patient Centred Care, University of Exeter Collaboration for Academic Primary Care (APEx), University of Exeter Medical School, University of Exeter, Exeter, UK.

Background: There is a growing interest in identifying strategies to achieve safer primary health-care provision. However, most of the research conducted so far in this area relies on information supplied by health-care providers, and limited attention has been paid to patients' perspectives.

Objective: To explore patients' experiences and perceptions of patient safety in English general practices with the aim of eliciting patient-centred recommendations for improving patient safety.

Methods: The Patient Reported Experiences and Outcomes of Safety in Primary Care questionnaire was sent to a random sample of 6736 primary care users registered in 45 English practices. We conducted a qualitative content analysis of responses to seven open-ended items addressing patients' experiences of safety problems, lessons learnt as a result of such experiences and recommendations for safer health care.

Results: A total of 1244 (18.4%) participants returned completed questionnaires. Of those, 678 (54.5%) responded to at least one open-ended question. Two main themes emerged as follows: (i) experiences of safety problems and (ii) good practices and recommendations to improve patient safety in primary care. Most frequent experiences of safety problems were related to appointments, coordination between providers, tests, medication and diagnosis. Patients' responses to these problems included increased patient activation (eg speaking up about concerns with their health care) and avoidance of unnecessary health care. Recommendations for safer health care included improvements in patient-centred communication, continuity of care, timely appointments, technical quality of care, active monitoring, teamwork, health records and practice environment.

Conclusion: This study identified a number of patient-centred recommendations for improving patient safety in English general practices.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/hex.12537DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5600214PMC
October 2017

New transfer of care initiative of electronic referral from hospital to community pharmacy in England: a formative service evaluation.

BMJ Open 2016 10 14;6(10):e012532. Epub 2016 Oct 14.

Pharmacy Department, Newcastle-upon-Tyne NHS Foundation Trust, Newcastle-upon-Tyne, UK.

Objectives: To evaluate an electronic patient referral system from one UK hospital Trust to community pharmacies across the North East of England.

Setting: Two hospital sites in Newcastle-upon-Tyne and 207 community pharmacies.

Participants: Inpatients who were considered to benefit from on-going support and continuity of care after leaving hospital.

Intervention: Electronic transmission of an information related to patient's medicines to their nominated community pharmacy. Community pharmacists to provide a follow-up consultation tailored to the individual patient needs.

Primary And Secondary Outcomes: Number of referrals made to and received by different types of pharmacies; reasons for referrals; accepted/completed and rejected referred rates; reasons for rejections by community pharmacists; time to action referrals; details of the follow-up consultations; readmission rates at 30, 60 and 90 days post referral and number of hospital bed days.

Results: 2029 inpatients were referred over a 13-month period (1 July 2014-31 July 2015). Only 31% (n=619) of these patients participated in a follow-up consultation; 47% (n=955) of referrals were rejected by community pharmacies with the most common reason being 'patient was uncontactable' (35%, n=138). Most referrals were accepted/completed within 7 days of receipt and most rejections were made >2 weeks after referral receipt. Most referred patients were over 60 years of age and referred for a Medicines Use Review (MUR) or enrolment for the New Medicines Service (NMS). Those patients who received a community pharmacist follow-up consultation had statistically significant lower rates of readmissions and shorter hospital stays than those patients without a follow-up consultation.

Conclusions: Hospital pharmacy staff were able to use an information technology (IT) platform to improve the coordination of care for patients transitioning back home from hospital. Community pharmacists were able to contact the majority of patients and results indicate that patients receiving a follow-up consultation may have lower rates of readmission and shorter hospital stays.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjopen-2016-012532DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5073802PMC
October 2016

Towards improved drug allergy alerts: Multidisciplinary expert recommendations.

Int J Med Inform 2017 01 6;97:353-355. Epub 2016 Oct 6.

General Internal Medicine & Primary Care, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; University of Colorado, Department of Emergency Medicine, Aurora, CO, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijmedinf.2016.10.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7213818PMC
January 2017

A systematic review of the types and causes of prescribing errors generated from using computerized provider order entry systems in primary and secondary care.

J Am Med Inform Assoc 2017 Mar;24(2):432-440

Division of Pharmacy, School of Medicine, Pharmacy and Health, Durham University, Stockton on Tees, Durham, UK.

Objective: To understand the different types and causes of prescribing errors associated with computerized provider order entry (CPOE) systems, and recommend improvements in these systems.

Materials And Methods: We conducted a systematic review of the literature published between January 2004 and June 2015 using three large databases: the Cumulative Index to Nursing and Allied Health Literature, Embase, and Medline. Studies that reported qualitative data about the types and causes of these errors were included. A narrative synthesis of all eligible studies was undertaken.

Results: A total of 1185 publications were identified, of which 34 were included in the review. We identified 8 key themes associated with CPOE-related prescribing errors: computer screen display, drop-down menus and auto-population, wording, default settings, nonintuitive or inflexible ordering, repeat prescriptions and automated processes, users' work processes, and clinical decision support systems. Displaying an incomplete list of a patient's medications on the computer screen often contributed to prescribing errors. Lack of system flexibility resulted in users employing error-prone workarounds, such as the addition of contradictory free-text comments. Users' misinterpretations of how text was presented in CPOE systems were also linked with the occurrence of prescribing errors.

Discussion And Conclusions: Human factors design is important to reduce error rates. Drop-down menus should be designed with safeguards to decrease the likelihood of selection errors. Development of more sophisticated clinical decision support, which can perform checks on free-text, may also prevent errors. Further research is needed to ensure that systems minimize error likelihood and meet users' workflow expectations.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/jamia/ocw119DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7651904PMC
March 2017

A literature review of the training offered to qualified prescribers to use electronic prescribing systems: why is it so important?

Int J Pharm Pract 2017 Jun 4;25(3):195-202. Epub 2016 Aug 4.

Division of Pharmacy, School of Medicine, Pharmacy and Health, Durham University, Stockton on Tees, UK.

Objectives: A key element of the implementation and ongoing use of an electronic prescribing (ePrescribing) system is ensuring that users are, and remain, sufficiently trained to use the system. Studies have suggested that insufficient training is associated with suboptimal use. However, it is not clear from these studies how clinicians are trained to use ePrescribing systems or the effectiveness of different approaches. We sought to describe the various approaches used to train qualified prescribers on ePrescribing systems and to identify whether users were educated about the pitfalls and challenges of using these systems.

Methods: We performed a literature review, using a systematic approach across three large databases: Cumulative Index Nursing and Allied Health Literature, Embase and Medline were searched for relevant English language articles. Articles that explored the training of qualified prescribers on ePrescribing systems in a hospital setting were included.

Key Findings: Our search of 'all training' approaches returned 1155 publications, of which seven were included. A separate search of 'online' training found three relevant publications. Training methods in the 'all training' category included clinical scenarios, demonstrations and assessments. Regarding 'online' training approaches; a team at the University of Victoria in Canada developed a portal containing simulated versions of electronic health records, where individuals could prescribe for fictitious patients. Educating prescribers about the challenges and pitfalls of electronic systems was rarely discussed.

Conclusions: A number of methods are used to train prescribers; however, the lack of papers retrieved suggests a need for additional studies to inform training methods.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/ijpp.12296DOI Listing
June 2017

The frequency of inappropriate nonformulary medication alert overrides in the inpatient setting.

J Am Med Inform Assoc 2016 09 21;23(5):924-33. Epub 2016 Mar 21.

Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, One Brigham Circle, Harvard Medical School, Boston, MA 02120, USA.

Background: Experts suggest that formulary alerts at the time of medication order entry are the most effective form of clinical decision support to automate formulary management.

Objective: Our objectives were to quantify the frequency of inappropriate nonformulary medication (NFM) alert overrides in the inpatient setting and provide insight on how the design of formulary alerts could be improved.

Methods: Alert overrides of the top 11 (n = 206) most-utilized and highest-costing NFMs, from January 1 to December 31, 2012, were randomly selected for appropriateness evaluation. Using an empirically developed appropriateness algorithm, appropriateness of NFM alert overrides was assessed by 2 pharmacists via chart review. Appropriateness agreement of overrides was assessed with a Cohen's kappa. We also assessed which types of NFMs were most likely to be inappropriately overridden, the override reasons that were disproportionately provided in the inappropriate overrides, and the specific reasons the overrides were considered inappropriate.

Results: Approximately 17.2% (n = 35.4/206) of NFM alerts were inappropriately overridden. Non-oral NFM alerts were more likely to be inappropriately overridden compared to orals. Alerts overridden with "blank" reasons were more likely to be inappropriate. The failure to first try a formulary alternative was the most common reason for alerts being overridden inappropriately.

Conclusion: Approximately 1 in 5 NFM alert overrides are overridden inappropriately. Future research should evaluate the impact of mandating a valid override reason and adding a list of formulary alternatives to each NFM alert; we speculate these NFM alert features may decrease the frequency of inappropriate overrides.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/jamia/ocv181DOI Listing
September 2016

Development of an algorithm to assess appropriateness of overriding alerts for nonformulary medications in a computerized prescriber-order-entry system.

Am J Health Syst Pharm 2016 Jan;73(1):e34-45

Qoua L. Her, Pharm.D., M.S., M.Sc., is Pharmacy Informatics and Outcomes Research Fellow, MCPHS University School of Pharmacy-Boston and Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital (BWH), Boston, MA. Diane L. Seger, B.S.Pharm., is Senior Pharmaco-Informatics Specialist, Clinical and Quality Analysis, Information Systems, Partners HealthCare System, Inc., Wellesley, MA. Mary G. Amato, Pharm.D., M.P.H., is Associate Professor of Pharmacy Practice, MCPHS University, Boston. Patrick E. Beeler, M.D., is Postdoctoral Research Fellow, Division of General Internal Medicine and Primary Care, BWH, and Research Fellow, Harvard Medical School, Boston. Olivia Dalleur, M.Pharm., Ph.D., is Research Associate in Medicine, Division of General Internal Medicine and Primary Care, BWH, and Assistant Professor in Clinical Pharmacy, Louvain Drug Research Institute, Clinical Pharmacy Research Group, Cliniques, Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium. Sarah P. Slight, M.Pharm., Ph.D., P.G.Dip., is Senior Lecturer/Associate Professor of Pharmacy Practice, Wolfson Research Institute, School of Medicine, Pharmacy and Health, Durham University, Queen's Campus, Stockton-on-Tees, England, and Visiting Research Scholar, Division of General Internal Medicine and Primary Care, BWH. Patricia C. Dykes, Ph.D., RN, FACMI, is Program Director, Center for Patient Safety, Research and Practice, BWH. David W. Bates, M.D., M.Sc., is Senior Vice President for Quality and Safety and Chief Quality Officer, Division of General Internal Medicine and Primary Care, BWH.

Purpose: An algorithm for assessing the appropriateness of physician overrides of clinical decision support alerts triggered by nonformulary medication (NFM) requests is described.

Methods: Data on a random sample of 5000 NFM alert overrides at Brigham and Women's Hospital over a four-year period (2009-12) were extracted from the hospital's computerized prescriber-order-entry (CPOE) system. Through an iterative process, a scheme for categorizing the reasons given by prescribers for alert overrides was developed. A pharmacist and a physician used the categorization scheme to classify and group alert override reasons, and the resultant data guided the development of an algorithm for assessing alert overrides.

Results: In free-text comments written in response to NFM alerts, prescribers provided more than 1150 unique reasons to justify formulary deviation. The compiled reasons were analyzed and grouped into nine categories through the iterative process, with a high degree of interrater agreement (κ = 0.989; 95% confidence interval, 0.985-0.992). An initially developed 30-item "NFM alert override appropriateness algorithm" was simplified to create an 8-question algorithm that was presented to an interdisciplinary team for evaluation, with subsequent refinements for enhanced clinical creditability. The final algorithm can be used by researchers and formulary managers to develop strategies for limiting NFM alert overrides and to avoid the labor-intensive task of creating appropriateness criteria for each NFM.

Conclusion: A multistep process was used to develop a generalized algorithm for categorizing the appropriateness of reasons given for NFM alert overrides in a CPOE system.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2146/ajhp150156DOI Listing
January 2016

Rising drug allergy alert overrides in electronic health records: an observational retrospective study of a decade of experience.

J Am Med Inform Assoc 2016 05 17;23(3):601-8. Epub 2015 Nov 17.

Division of General Internal Medicine & Primary Care, Brigham and Women's Hospital, Boston, MA, USA Harvard Medical School, Boston, MA, USA Clinical & Quality Analysis, Partners Healthcare System, Wellesley, MA, USA.

Objective: There have been growing concerns about the impact of drug allergy alerts on patient safety and provider alert fatigue. The authors aimed to explore the common drug allergy alerts over the last 10 years and the reasons why providers tend to override these alerts.

Design: Retrospective observational cross-sectional study (2004-2013).

Materials And Methods: Drug allergy alert data (n = 611,192) were collected from two large academic hospitals in Boston, MA (USA).

Results: Overall, the authors found an increase in the rate of drug allergy alert overrides, from 83.3% in 2004 to 87.6% in 2013 (P < .001). Alarmingly, alerts for immune mediated and life threatening reactions with definite allergen and prescribed medication matches were overridden 72.8% and 74.1% of the time, respectively. However, providers were less likely to override these alerts compared to possible (cross-sensitivity) or probable (allergen group) matches (P < .001). The most common drug allergy alerts were triggered by allergies to narcotics (48%) and other analgesics (6%), antibiotics (10%), and statins (2%). Only slightly more than one-third of the reactions (34.2%) were potentially immune mediated. Finally, more than half of the overrides reasons pointed to irrelevant alerts (i.e., patient has tolerated the medication before, 50.9%) and providers were significantly more likely to override repeated alerts (89.7%) rather than first time alerts (77.4%, P < .001).

Discussion And Conclusions: These findings underline the urgent need for more efforts to provide more accurate and relevant drug allergy alerts to help reduce alert override rates and improve alert fatigue.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/jamia/ocv143DOI Listing
May 2016

The vulnerabilities of computerized physician order entry systems: a qualitative study.

J Am Med Inform Assoc 2016 Mar 13;23(2):311-6. Epub 2015 Nov 13.

The Center for Patient Safety Research and Practice, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA. Harvard Medical School, 250 Longwood Ave, Boston, MA, USA.

Objective: To test the vulnerabilities of a wide range of computerized physician order entry (CPOE) systems to different types of medication errors, and develop a more comprehensive qualitative understanding of how their design could be improved.

Materials And Methods: The authors reviewed a random sample of 63,040 medication error reports from the US Pharmacopeia (USP) MEDMARX reporting system where CPOE systems were considered a "contributing factor" to errors and flagged test scenarios that could be tested in current CPOE systems. Testers entered these orders in 13 commercial and homegrown CPOE systems across 16 different sites in the United States and Canada, using both usual practice and where-needed workarounds. Overarching themes relevant to interface design and usability/workflow issues were identified.

Results: CPOE systems often failed to detect and prevent important medication errors. Generation of electronic alert warnings varied widely between systems, and depended on a number of factors, including how the order information was entered. Alerts were often confusing, with unrelated warnings appearing on the same screen as those more relevant to the current erroneous entry. Dangerous drug-drug interaction warnings were displayed only after the order was placed rather than at the time of ordering. Testers illustrated various workarounds that allowed them to enter these erroneous orders.

Discussion And Conclusion: The authors found high variability in ordering approaches between different CPOE systems, with major deficiencies identified in some systems. It is important that developers reflect on these findings and build in safeguards to ensure safer prescribing for patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/jamia/ocv135DOI Listing
March 2016