Outcomes on Implementation of Electronic Medication Administration Records and CPOE

Alan Chan, MDInternal Medicine-Pediatrics

Mentors

• Michael Huke, Pharm D. • Melissa Gabriel, Pharm.D., BCPS • Jeff Hackman, MD – Emergency Dept.

Disclaimer

• I was working on the CDC Universal Data Collection project for hemophilia and other blood disorders for adult and pediatrics.

• A couple months ago, the project was shelved due to funding cuts and delays.

• I’m not sure if I should blame the federal budget cuts…

• Full statistical analysis is not completed.

Background

• Something big happened at the end of August 2010!

• Cerner GO-Live/Q6 for the CPOE (or Computer Physician Order entry) !!!• This will be referred to as the “start date”.

The Institute of Medicine• In 1999 article, notes 44,000 to 98,000

deaths due to medical errors. • To what extent these are directly related

are debatable. • Computer physician order entry is one of

the benchmarks for patient safety. • Defined by Leapfrog Group along with ICU

staffing, High risk treatments/procedures, and Safe Practices Score

• Also part of HITECH Act of 2009.

• http://www.leapfroggroup.org/for_consumers/hospitals_asked_what accessed 4/1/2011

University HealthSystem Consortium (UHC)• Consists of 113 academic medical

centers and affialiated hospitals – 90% of nations non-profits academic medical centers

• Patient Safety Net (PSN) is a real time, Web-based event reporting system.

• At Truman Medical Center (TMC), events can be logged into the system by any health care provider.

• https://www.uhc.edu/11851.htm accessed 4/1/2011

Objective

• We believe that the initiation of the CPOE and electronic medication administration record (eMAR) would decrease total errors.

• What new errors might be introduced?• Few studies exist to track these changes.

Methods

• Search on PubMed limited to past 5 years, English print journals, and Humans.

• Terms included “electronic medical records and patient safety” for 228 results and “Adverse drug events computer physician order “ with 51 results.

• Some immediate references and citations to these results were used, which could include older articles.

• http://www.ncbi.nlm.nih.gov accessed 4/1/2011

Methods (cont)

• TMC – all areas (inpatient, outpatient, ER, BH)

• CPOE system – Powerchart; Cerner • A retrospective review of PSN results

were used – these are self reported. • Time frame of 1, 3, and 6 months pre

and post implementation were used. • A random sampling of 1 and 3 month

windows were done to ensure similar number of reports.

Variables

• Looked at ALL medications errors (med errors)– Sub groups of wrong medication and

incorrect medication list separately and also together.

• Looked at Adverse Drug Reactions (ADR), but not medication errors.

• In these Med errors, looked at the type of outcome, whether it created an “Unsafe, No Harm, or Harmful Event”.

Medication errors – 9 types

1. Dose omission2. Extra dose given3. Wrong medication4. Prescription/refill delay5. Medication list was incorrect6. Monitoring error (includes

contraindications)7. Unauthorized drug8. Inadequate pain management9. Other

Harm Score or Category of Events• Unsafe conditions (A)• Event, but no Harm

– B1 – near miss from chance– B2 – near miss because of recovery efforts– C – reached patient (pt), but no harm– D – reached pt, and required additional monitoring

to prevent harm• Event, but Harm

– E – pt temporary harm, and required treatment– F – pt temporary harm, and required more

hospitalization– G – permanent harm– H – harm and required intervention to sustain life

like ICU transfer• Death (I) – one case, but unique circumstance. • Undetermined (X) - no cases

Results – 1 month window

1 monthALL errorsmed error wrong med med list wrong ADR

PRE 74 35 28 7 5POST 62 23 20 3 2ARR % 12 12 8 4 3RRR % 16.2 34.3 28.6 57.1 60

PRE = before “start date”; POST = after “start date”; ARR% is the Absolute risk reduction; RRR % is the relative risk reduction

Results – 3 month window

3 monthALL errorsmed error wrong med med list wrong ADR

PRE 198 101 79 22 17POST 174 66 58 8 11ARR % 24 35 21 14 6RRR % 12.1 34.7 26.6 63.6 35.3

Results – 6 month window

6 monthALL errorsmed error wrong med med list wrong ADR

PRE 421 183 136 47 34POST 289 107 93 14 26ARR % 132 76 43 33 8RRR % 31.4 41.5 31.6 70.2 23.5

Results…

• A few single months were checked before and after “start date”, and the overall results number of reported events are similar

• The overall number of reports have been increasing over the past few years, so difficult to access much before the “start date”.

• Overall, all types of errors are lower. **

Results – Harm score

6 monthunsafe event - no harm event - harm total

PRE 16 393 12 421POST 30 242 17 289

These are number of medication errors

More errors?

• Why more Unsafe errors?– More wrong med errors (from 5 to 10)– New type of error – delay in getting med– A contraindication was displayed and noted– Other types

• Why More Harmful errors?– Actually less “Omission errors”– More wrong med errors (from 5 to 7)– Other types

• The “other types” may be mislabeled**.

Discussion• User generated reports, although members of

the PSN team here review reports as they are generated in real-time.

• Some other reports may not have been correctly classified.

• New unintended consequences – one study at a tertiary pediatric center actually noted increased mortality.

• Might affect time sensitive therapies like critical care settings.

• Han YY, Carcillo JA, Venkataraman ST, et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system

Next steps

• Review 1 year data• Evaluate whether this represents a fair

sample of the cases.• Review the “other category” to make

sure properly labeled cases• Look at ADR and mortality, latter difficult

to evaluate with this.

Notable thoughts. • It takes time for providers to adopt• Pharmacy centralizes many medications• Providers may spend more time away from bedside• Physician workload will increase, but uncertain

amount– Is this trade off worth the better documentation

and e-paper trail? • More order set would decrease “click through” time• Delays in opening electronic charts during heavy

work times• Self reported events and ADR may not correlate

with true rate.

Other thoughts

• One study at a pediatric hospital saw overall decrease in hospital wide mortality with CPOE and electronic nursing documentation.

• Studies at ICU areas show decrease in risk of medication errors, but no significant reduction in ADR or mortality.

• Many studies have not been fully powered to detect the small number of ADR or mortality though.

• We can look at 1 year data from “start date”.

References• http://www.leapfroggroup.org/for_consumers/hospitals_asked_what accessed 4/1/2011 • Han YY, Carcillo JA, Venkataraman ST, et al. Unexpected increased mortality after implementation of a commercially

sold computerized physician order entry system [published correction appears in Pediatrics. 2006;117(2):594]. Pediatrics. 2005;116(6):1506–1512.

• Van Rosse F, Maat B, Carin MA, et al. The Effect of CPOE on Medication Prescription Errors and Clinical Outcome in Pediatric and Intensive Care: A Systemic Review. Pediatrics. 2009; 123(4): 1184-1190.

• Sittig DF, Ash JS, Zhang J, et al. Lessons From "Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry System“. Pediatrics. 2006; 118; 797-801.

• Longhurst CA, Parast L, Sandbord CI, et al. Decrease in Hospital-wide Mortality Rate After• Implementation of a Commercially Sold Computerized Physician Order Entry System. Pediatrics. 2010; 126: 14-21. • Kaushal R, Shojania KG, Bates DW. Effects of Computerized Physician Order Entry and Clinical Decision Support Systems

on Medication Safety. Arch Intern Med. 2003; 163: 1409-1416.• http://www.cpoe.org/ From Oregon Health and Sciences University. Accessed 4/1/2011