Cincinnati Children's Hospital Medical Center is in the vanguard of medication management safety in the United States, thanks to an initiative led by one its pediatricians, who has also been its director of technology and patient safety. And, says that physician, none of the hospital's advances could have been made without computer-based provider order entry (CPOE).
“We care for a lot of very sick children, use a lot of technology, and throw a lot of plans and medications and treatments at them, so it's a potentially highly toxic environment,” says Brian Jacobs, M.D., the leader of Cincinnati Children's Hospital's medication safety initiative. (In August, Jacobs accepted an offer from Children's National Medical Center in Washington, D.C., to move there and spearhead a similar initiative).
“The risks to medication safety are quite high in pediatric hospitals compared to in typical adult floor beds,” he adds.
Since rolling out its CPOE system in 2002, Jacobs reports, the 423-bed hospital has documented numerous medication safety gains. Its intensive-care unit (ICU) mortality rate has dropped steadily from 4.6 percent prior to CPOE rollout, to 3.1 percent last year. At the same time, 92 percent of orders are now entered directly by physicians or nurse practitioner-prescribers into the system (versus 22 percent of medication orders historically given verbally). And medication administration turnaround time to the bedside has dropped from two hours to one, improving antibiotic therapy to patients.
Most exciting of all, though, is the proactive, automated error-detection program that Jacobs established, and which relies on the CPOE system for its electronic triggers.
“We've found 10–12-fold underreporting of errors,” Jacobs notes. “Using an automated detection system is a way to truly understand your errors, and even more importantly, to proactively redesign care processes to proactively avert events.”
The detection system automatically trawls the electronic medication administration record (eMAR) for certain events, searching for administration of opiate antidotes, for example. In that example, 70 percent of opiate antidote dispensations have been traced to some kind of triggering medication error. Given such incidents, the system automatically alerts clinical risk managers to investigate and find out what occurred.
“So this is a tremendous way for an EMR to automatically detect errors taking place in your hospital. This allows you to look at an overall picture and design strategies. If I have 10 morphine errors a month but only one is reported, I'm going to make changes.” Most importantly, a hospital-wide medication safety committee is constantly finding ways to rework clinical processes for greater medication safety, based on the data the error-detection program uncovers, he says.
Next month: Advancing patient safety at the bedside.
Nationwide push for safety
Industry experts say that, thanks to an intense public and policy focus on medication safety, improvements in technology, and most of all, the implementation of electronic medical records (EMRs), eMAR and CPOE systems in hospitals, medication safety improvement is finally happening.
“Speaking as a pharmacist, I'll say that pharmacy has for years been making headway in getting involved in more clinical aspects of the process; so the pharmacy's having a major impact in improving meds use,” says David Troiano, a Houston-based senior manager at Long Beach, Calif.-based First Consulting Group, who advises hospital organizations on medication management- and CPOE-related issues. “I think organizations are doing well in raising awareness of medical errors and medication errors specifically; I don't think they're having as much success with reporting errors.”
Still, he says, somewhere between 25 and 50 percent of hospitals are moving forward at varying speeds with CPOE, bar-coded medication administration, and “smart-pump” implementations. And, he adds, EMR, eMAR and CPOE capabilities will be absolutely necessary in order to make significant medication safety gains going forward.
Troiano's colleague, research director Fran Turisco, who is in FCG's Boston office, has been working with colleague Jane Metzger on a project helping a national children's hospital association analyze the gaps in interfaces between medication-related information systems (EMR, eMAR, CPOE), and where processes tend to break down.
“One of the toughest things to manage,” Turisco says, “is the transition between what the physician orders and what actually gets dispensed. The way a physician orders a medication is going to be different from the way a pharmacy sees it and dispenses it; the data is presented differently. The smarter pharmacy systems provide a display to show generic equivalents in different doses.”
Computer-based Provider Order Entry
CPOE is the portion of a clinical information system that enables a patient's care provider to enter an order for a medication, clinical laboratory or radiology test, or procedure directly into the computer. The system then transmits the order to the appropriate department, or individuals, so it can be carried out. The most advanced implementations of such systems also provide real-time clinical decision support such as dosage and alternative medication suggestions, duplicate therapy warnings, and drug-drug and drug-allergy interaction checking (Osheroff, 2005).