Impact of Computerized Physician Order Entry in the ICU
Impact of Computerized Physician Order Entry in the ICU
Introduction: Medication errors in the intensive care unit (ICU) are frequent and lead to attributable patient morbidity and mortality, increased length of ICU stay and substantial extra costs. We investigated if the introduction of a computerized ICU system (Centricity Critical Care Clinisoft, GE Healthcare) reduced the incidence and severity of medication prescription errors (MPEs).
Methods: A prospective trial was conducted in a paper-based unit (PB-U) versus a computerized unit (C-U) in a 22-bed ICU of a tertiary university hospital. Every medication order and medication prescription error was validated by a clinical pharmacist. The registration of different classes of MPE was done according to the National Coordinating Council for Medication Error Reporting and Prevention guidelines. An independent panel evaluated the severity of MPEs. We identified three groups: minor MPEs (no potential to cause harm); intercepted MPEs (potential to cause harm but intercepted on time); and serious MPEs (non-intercepted potential adverse drug events (ADE) or ADEs, being MPEs with potential to cause, or actually causing, patient harm).
Results: The C-U and the PB-U each contained 80 patient-days, and a total of 2,510 medication prescriptions were evaluated. The clinical pharmacist identified 375 MPEs. The incidence of MPEs was significantly lower in the C-U compared with the PBU (44/1286 (3.4%) versus 331/1224 (27.0%); P < 0.001). There were significantly less minor MPEs in the C-U than in the PB-U (9 versus 225; P < 0.001). Intercepted MPEs were also lower in the C-U (12 versus 46; P < 0.001), as well as the non-intercepted potential ADEs (21 versus 48; P < 0.001). There was also a reduction of ADEs (2 in the C-U versus 12 in the PBU; P < 0.01). No fatal errors occurred. The most frequent drug classes involved were cardiovascular medication and antibiotics in both groups. Patients with renal failure experienced less dosing errors in the C-U versus the PB-U (12 versus 35 serious MPEs; P < 0.001).
Conclusion: The ICU computerization, including the medication order entry, resulted in a significant decrease in the occurrence and severity of medication errors in the ICU.
In 1999, the Institute Of Medicine reported that 44,000 to 98,000 people annually die in US hospitals as a result of medical errors. Medication errors occurring either in or out of the hospital are estimated to account for at least 7,000 deaths each year. Medication errors can occur in all stages of the medication process, from prescribing to dispensing and administration of the drug. Although most of these errors are harmless, or intercepted on time, some do result in an adverse drug event (ADE). According to Bates and colleagues, 1/100 in-hospital medication errors result in an ADE, and 7/100 have the potential to do so. Overall, 28% to 56% of all ADEs are judged preventable, and most of these errors occur in the ordering stage of the medication process. It has been shown that the attributable cost ranges from $10 for a medication error without harm, to more than $5,000 for a serious ADE. In intensive care unit (ICU) settings, the rate of preventable and potential ADEs is even higher, being almost twice as high as in non-ICUs. This can be attributed to the high number of drugs that ICU patients receive, the preference for intravenous administration and the incidence of organ failure, all of which increase the potential for errors.
Studies published by the ADE Prevention Study Group indicate that prevention strategies targeting systems rather than individuals are more effective in reducing errors. Computerized physician order entry (CPOE) has been recommended by the Leapfrog group as a major step to improve patient safety in the USA. CPOE could eliminate many of the problems associated with manual drug order writing by decreasing the occurrence of illegible orders, inappropriate doses and incomplete orders, which results in a substantial reduction in medication errors of 55% to 80%. On the other hand, less sophisticated or older CPOE systems may have the potential to introduce new problems. Until now, CPOE has never been shown to decrease patient morbidity or mortality, but seems to be especially helpful in preventing minor errors. An intensive care information system (ICIS) is a computerized system specifically designed for the ICU. All recent commercial ICISs have incorporated CPOE, and some systems combine this with varying degrees of clinical decision support systems (CDSSs). Only a few authors have studied the impact of CPOE in the ICU, and even less have investigated the occurrence of medication prescription errors before and after the implementation of an ICIS. A recent article by Shulman and colleagues showed that CPOE without CDSS was able to eliminate many of the minor errors, but introduced new, potentially more serious errors in their ICU.
In one unit of our ICU, we implemented an ICIS with incorporated CPOE and a moderate level of CDSS. The objective of this study was to evaluate and compare the incidence and severity of medication prescribing errors (MPEs) between this CPOE unit and paper-based units.
Introduction: Medication errors in the intensive care unit (ICU) are frequent and lead to attributable patient morbidity and mortality, increased length of ICU stay and substantial extra costs. We investigated if the introduction of a computerized ICU system (Centricity Critical Care Clinisoft, GE Healthcare) reduced the incidence and severity of medication prescription errors (MPEs).
Methods: A prospective trial was conducted in a paper-based unit (PB-U) versus a computerized unit (C-U) in a 22-bed ICU of a tertiary university hospital. Every medication order and medication prescription error was validated by a clinical pharmacist. The registration of different classes of MPE was done according to the National Coordinating Council for Medication Error Reporting and Prevention guidelines. An independent panel evaluated the severity of MPEs. We identified three groups: minor MPEs (no potential to cause harm); intercepted MPEs (potential to cause harm but intercepted on time); and serious MPEs (non-intercepted potential adverse drug events (ADE) or ADEs, being MPEs with potential to cause, or actually causing, patient harm).
Results: The C-U and the PB-U each contained 80 patient-days, and a total of 2,510 medication prescriptions were evaluated. The clinical pharmacist identified 375 MPEs. The incidence of MPEs was significantly lower in the C-U compared with the PBU (44/1286 (3.4%) versus 331/1224 (27.0%); P < 0.001). There were significantly less minor MPEs in the C-U than in the PB-U (9 versus 225; P < 0.001). Intercepted MPEs were also lower in the C-U (12 versus 46; P < 0.001), as well as the non-intercepted potential ADEs (21 versus 48; P < 0.001). There was also a reduction of ADEs (2 in the C-U versus 12 in the PBU; P < 0.01). No fatal errors occurred. The most frequent drug classes involved were cardiovascular medication and antibiotics in both groups. Patients with renal failure experienced less dosing errors in the C-U versus the PB-U (12 versus 35 serious MPEs; P < 0.001).
Conclusion: The ICU computerization, including the medication order entry, resulted in a significant decrease in the occurrence and severity of medication errors in the ICU.
In 1999, the Institute Of Medicine reported that 44,000 to 98,000 people annually die in US hospitals as a result of medical errors. Medication errors occurring either in or out of the hospital are estimated to account for at least 7,000 deaths each year. Medication errors can occur in all stages of the medication process, from prescribing to dispensing and administration of the drug. Although most of these errors are harmless, or intercepted on time, some do result in an adverse drug event (ADE). According to Bates and colleagues, 1/100 in-hospital medication errors result in an ADE, and 7/100 have the potential to do so. Overall, 28% to 56% of all ADEs are judged preventable, and most of these errors occur in the ordering stage of the medication process. It has been shown that the attributable cost ranges from $10 for a medication error without harm, to more than $5,000 for a serious ADE. In intensive care unit (ICU) settings, the rate of preventable and potential ADEs is even higher, being almost twice as high as in non-ICUs. This can be attributed to the high number of drugs that ICU patients receive, the preference for intravenous administration and the incidence of organ failure, all of which increase the potential for errors.
Studies published by the ADE Prevention Study Group indicate that prevention strategies targeting systems rather than individuals are more effective in reducing errors. Computerized physician order entry (CPOE) has been recommended by the Leapfrog group as a major step to improve patient safety in the USA. CPOE could eliminate many of the problems associated with manual drug order writing by decreasing the occurrence of illegible orders, inappropriate doses and incomplete orders, which results in a substantial reduction in medication errors of 55% to 80%. On the other hand, less sophisticated or older CPOE systems may have the potential to introduce new problems. Until now, CPOE has never been shown to decrease patient morbidity or mortality, but seems to be especially helpful in preventing minor errors. An intensive care information system (ICIS) is a computerized system specifically designed for the ICU. All recent commercial ICISs have incorporated CPOE, and some systems combine this with varying degrees of clinical decision support systems (CDSSs). Only a few authors have studied the impact of CPOE in the ICU, and even less have investigated the occurrence of medication prescription errors before and after the implementation of an ICIS. A recent article by Shulman and colleagues showed that CPOE without CDSS was able to eliminate many of the minor errors, but introduced new, potentially more serious errors in their ICU.
In one unit of our ICU, we implemented an ICIS with incorporated CPOE and a moderate level of CDSS. The objective of this study was to evaluate and compare the incidence and severity of medication prescribing errors (MPEs) between this CPOE unit and paper-based units.
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