Post on 11-Jul-2020
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Errors Associated with the Errors Associated with the Use of EUse of E--PrescribingPrescribing
Eric Poon MD, MPHEric Poon MD, MPHIS Director of Clinical Informatics, IS Director of Clinical Informatics,
Associate Physician, Associate Physician, Brigham and WomenBrigham and Women’’s Hospital, Boston, MAs Hospital, Boston, MA
Assistant Professor, Harvard Medical SchoolAssistant Professor, Harvard Medical School
Supported by a grant from the Risk Management Foundation
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AgendaAgenda
Errors associated with eErrors associated with e--prescribingprescribingTaxonomy with examplesTaxonomy with examplesContributing factorsContributing factors
E-Prescribing Comes of Age!
Strong evidence that electronic prescribing in the inpatient setting prevents serious medication errors
Emerging evidence in the ambulatory settingSignificant interest at the local, state, and federal level
100% e-prescribing target for PCPs and specialists at Partners HealthcareUse of e-prescribing as P4P metricNational efforts
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Unintended Consequences: The Underbelly Unintended Consequences: The Underbelly of Healthcare Information Technology (HIT)of Healthcare Information Technology (HIT)
Events or outcomes that are neither Events or outcomes that are neither anticipated noranticipated nor the specific goals of the the specific goals of the associated HIT associated HIT
May be negative or positiveMay be negative or positiveBest studied more recently in the inpatient Best studied more recently in the inpatient settingsetting
New errors from use of inpatient CPOE has New errors from use of inpatient CPOE has received significant attentionreceived significant attention
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New Errors: New Errors: Revisiting an Old PhenomenonRevisiting an Old Phenomenon
New errors observed in the inpatient New errors observed in the inpatient setting (Koppel, Han, Ash)setting (Koppel, Han, Ash)
Extend and severity not fully understood in Extend and severity not fully understood in the outpatient settingthe outpatient setting
Study goalsStudy goalsDevelop taxonomy to classify errorsDevelop taxonomy to classify errorsDescribe contributing factorsDescribe contributing factors
Range of Errors Associated with e-prescribing
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Key Components of a prescriptionKey Components of a prescription
Drug productDrug productDoseDoseFrequencyFrequencyRouteRouteDispensing quantityDispensing quantityRefill quantitiesRefill quantitiesInstructionsInstructionsIdentification and authentication of prescriberIdentification and authentication of prescriber
MethodsDrafting of Taxonomy
2 sets of electronic prescriptions with errors reviewedConvenience sample at CRICO site 1, collected by outpatient pharmacist and medical director of adult primary care practice (200+ prescriptions)Electronic prescription reviewed at CRICO site 2 as part of AHRQ-funded project to evaluate new e-prescribing standards
Validation of Taxonomy2 focus groups with community pharmacists
Contributing factorsRecreation of prescriptions with errors in native systemConsultation with informatics and IT professionals
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Drug Product Errors Drug Product Errors
Incomplete Drug NameIncomplete Drug NameStrength Omitted or Error in StrengthStrength Omitted or Error in StrengthIncorrect Drug Chosen and Script Incorrect Drug Chosen and Script Manually AlteredManually Altered
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Error in Product StrengthError in Product Strength
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Dose ErrorsDose Errors
Dose OmittedDose OmittedIncorrect DoseIncorrect DoseAmbiguity in Sig FieldAmbiguity in Sig FieldDose IncompleteDose IncompleteOverdoseOverdoseUnderdoseUnderdose
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Ambiguous DoseAmbiguous Dose11.25mg once
a day, or 7.5mg once a
day?
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Ambiguity in Sig FieldAmbiguity in Sig Field
Which do you trust? The
computer or the provider’s
Spanish?
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Route ErrorsRoute Errors
Incorrect RouteIncorrect RouteOmitted and Should Be POOmitted and Should Be POOmitted and should be Other RouteOmitted and should be Other Route
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Route IncorrectRoute Incorrect
Underlying cause: Inadequate synonym support in medication lookup ‘Nuva ring’ (not recognized) vs ‘Nuvaring’ (recognized)
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Frequency ErrorsFrequency Errors
Frequency OmittedFrequency OmittedFrequency ChangedFrequency Changed
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Ambiguous frequency with Ambiguous frequency with incorrect handincorrect hand--written alterationwritten alteration
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Special InstructionsSpecial InstructionsDose MismatchDose MismatchDrug Product Strength MismatchDrug Product Strength MismatchDose Form MismatchDose Form MismatchFrequency MismatchFrequency MismatchRoute Dosage Form MismatchRoute Dosage Form MismatchPRN is Indicated in Special Instructions but not in the PRN is Indicated in Special Instructions but not in the Sig. Sig. Duration of Therapy MismatchDuration of Therapy MismatchQuantity MismatchQuantity MismatchDose and Frequency MismatchDose and Frequency MismatchPRN Indication MismatchPRN Indication MismatchPrevious Special Instructions Carrying over on RenewalPrevious Special Instructions Carrying over on Renewal
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Directions that contradict rest of the Directions that contradict rest of the prescriptionprescription
Provider lack of familiarity with ‘alternate dosing’ prescribing method
Factors Contributing to Errors: A Preliminary Look
Categories of Contributing Factors
Technology Factors
Environmental FactorsUser Factors•Knowledge deficit about application features•Knowledge deficit about the prescription •Multi-tasking•Improper use of short-cuts•Improper use of free-text
•User-interface design•Medication dictionary•Data entry form factor
•Lack of time during visit•Placement of computer equipment
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Dissecting an Dissecting an ErrorError
What the prescribing module would have looked like…
7.5 mg
Free Text Entry Possible at the
time
Dose field relatively new to clinicians
History
1. Patient’s BP not well controlled on 5mg of Norvasc
qd. Increase to 7.5mg qd
3. Instead of specifying the higher dose in the dose field, provider entered the dose as free text in
the strength/form field
2. Norvasc only available in 2.5mg, 5 mg,and 10mg tablets
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Writing prescriptions Writing prescriptions –– do we know how to?do we know how to?
How much training have you received?Has anyone ever shown you this relationship?
Dose
Strength Take
Dose Dose ≈≈
Strength x TakeStrength x Take
Lisinopril 40mg Lisinopril 40mg po once a daypo once a day
Lisinopril 20mg Lisinopril 20mg tabletstablets
Take one tablet Take one tablet a daya day
Other common contributing factors
Medication dictionary issuesWrong/not available product in dictionary
Multi-tasking/distractions/short-cutsNot seeing/checking what is actually been typed in
Keyboard vs. pen;
Propagation of previous errorsCarry forward of erroneous information during renewals
Preliminary Recommendations
Possible User InterventionsFocused training on use of e-prescribing module
Hands-on, real-life examples‘Real life’ contextFocus on common errorsOngoing effort
Education about the prescriptionMedical students & physicians in training
Develop mechanism so that prescription errors become teaching tools.Develop and disseminate best practices for how to incorporate EMR into the visit
Possible Technology Interventions
Usability study/pilot before new features go-liveExplore different form factors for data entryMonitor for use of free-text in structured fieldsFormalize mechanism for using prescription errors as opportunities to improve user-interface design
Examples of recent improvements
Relationship between dose, strength and take
made more explicitWarning appears when
free text instructions are typed in
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Concluding RemarksConcluding Remarks
EE--prescribing has significant potential to prescribing has significant potential to improve medication safetyimprove medication safetyLike all other technologies, eLike all other technologies, e--prescribing prescribing opens doors to new errors. opens doors to new errors.
Causation often multiCausation often multi--factorialfactorialFrustratingly commonFrustratingly common--placeplace
Investment in time, energy and Investment in time, energy and mechanism for interventionsmechanism for interventions
Are we still in denial?
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AcknowledgementsAcknowledgements
Thomas Moniz, Thomas Moniz, RPhRPhJeff Rothschild, MD MPHJeff Rothschild, MD MPHMatveyMatvey PalchukPalchuk, MD MS , MD MS Matthew Matthew DitmoreDitmoreHans Kim, MDHans Kim, MD