Researchers get positive results with CPOE
Researchers get positive results with CPOE
Fewer bad prescriptions made
A computerized warning system could help hospitals reduce medication errors and improve patient safety, particularly among older patients, a new study shows.
Researchers at Beth Israel Deaconess Medical Center in Boston, MA, tailor-made a computerized provider order entry (CPOE) system that now has a built-in warning system that helps prevent medication mistakes.
The system uses the Beers Criteria, a list of medications that are considered dangerous for elderly people. Embedded alert warnings notify physicians when they've selected a medication that should not be used in people ages 65 and older, says Melissa L. P. Mattison, MD, an instructor in medicine at Harvard Medical School and Beth Israel Deaconess Medical Center in Boston, MA.
Mattison and co-investigators studied the alert system's impact on prescribers' medication orders and found that after the alert system was used, the mean rate of ordering medications that were not recommended had dropped from 11.56 orders per day to 9.94 orders per day.1
"We found the total number of orders over the study period dropped almost immediately by 16%, but the effect was a 23% decrease," she says. "This is because the total number of patients in the hospital increased over this time period, so the actual order for these medications dropped 23%."
The electronic warning pops up on desktop computers at the nursing stations and other computers that physicians use to make a prescription. The warning will advise precaution with a particular medication. The text will follow the Beers Criteria and study, Mattison explains.
For example, one screen precaution for Diphenhydramine in geriatric patients states: "Comments: May cause confusion and sedation. Should not be used as a hypnotic, and when used to treat emergency allergic reactions, it should be used in the smallest possible dose.1 Risk is increased in patients with Neurologic/Psychiatric impairment."
Physicians can override the warning, but they'll need to check a box on the electronic page, titled, "Geriatric Precaution Found." The override choices include these:
Patient stabilized on regimen; will monitor appropriate drug levels or laboratory values;
Interaction noted, regimen clinically indicated, will closely monitor;
Warning noted, will use smaller dose and monitor for side effects;
Other (fill in reason below).
The electronic medication warning study's results of a decrease in inappropriate medication orders were primarily impacted by a decrease in prescriptions for diphenhydramine (Benadryl®), Mattison says.
"Apparently, Benadryl was very commonly used as a sleep aid," she adds. "But it can cause urinary retention and confusion in older people, so we were warning people to use caution when prescribing Benadryl for allergic reactions."
The electronic warning system also has been useful in letting prescribers know when a medication dose is too high for a particular patient.
For instance, the hospital modified the system to include an alternative dosing option for orders of antipsychotic medications for older patients, Mattison says.
"We found a lot of times when people were writing orders for haloperidol they'd make it a 5 mg order, which is what is recommended for young, psychotic people," she explains. "We said that's a lot of medication to give an older, frail patient."
So now, anytime a doctor tries to order haloperidol for someone who is 65 years of age or older in the hospital, then they're taken to an electronic screen that provides a quick pick option for the user to click on ordering 0.5 mg of the drug, Mattison says.
This same option is available other antipsychotic drugs and analgesics.
"Some of this is based on expert opinion," Mattison says. "When we created this next generation of caring for older people, we sat with geriatricians, psychiatrists, nurses, doctors, pharmacists, and asked them what they thought would work and what the starting dose should be for this medication."
The electronic warning system's impact could extend to positive outcomes in reducing length of stay (LOS), preventing rehospitalizations, and cutting health utilization costs, but these have not been studied yet, Mattison notes.
Still, the drop in prescriptions of inappropriate medications should be enough of an incentive to convince other hospitals to use an electronic warning system that incorporates Beers Criteria, she says.
"It would be nice if CPOEs could take some of these tailor-made interventions for vulnerable populations," she says. "These targeted interventions would be more effective at changing care and guiding appropriate care."
While most hospitals won't have the resources to do an intervention like this one on their own, they could make use of an electronic warning system if it were part of a nationally-distributed CPOE system, she adds.
"Whether you're in rural Georgia or New York City, if you're 85 years old and have kidney failure, you'll be vulnerable to medications in a way that younger patients aren't," Mattison says. "So the more we can create smart systems that take the burden off the shoulders of every pharmacist and hospital in the country, the better."
Reference
- Mattison MLP, Afonso KA, Ngo LH, et al. Preventing potentially inappropriate medication use in hospitalized older patients with a computerized provider order entry warning system. Arch Intern Med. 2010;170(15):1331-1336.
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