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Medication Safety in Ambulatory Care
Thursday, February 15, 200712:00 – 1:00 p.m. Eastern Time
Moderator: Karen Frush, MD, FAAPChief Patient Safety OfficerDuke University Health SystemDurham, North Carolina
This activity was funded through an educational grant from the Physicians’
Foundation for Health Systems Excellence.
Disclosure of Financial Relationships and Resolution of Conflicts of Interest for AAP CME Activities Grid
The AAP CME program aims to develop, maintain, and increase the competency, skills, and professional performance of pediatric healthcare professionals by providing high quality, relevant, accessible and cost-effective educational experiences. The AAP CME program provides activities to meet the participants’ identified education needs and to support their lifelong learning towards a goal of improving care for children and families (AAP CME Program Mission Statement, August 2004).
The AAP recognizes that there are a variety of financial relationships between individuals and commercial interests that require review to identify possible conflicts of interest in a CME activity. The “AAP Policy on Disclosure of Financial Relationships and Resolution of Conflicts of Interest for AAP CME Activities” is designed to ensure quality, objective, balanced, and scientifically rigorous AAP CME activities by identifying and resolving all potential conflicts of interest prior to the confirmation of service of those in a position to influence and/or control CME content. The AAP has taken steps to resolve any potential conflicts of interest.
All AAP CME activities will strictly adhere to the 2004 Updated Accreditation Council for Continuing Medical Education (ACCME) Standards for Commercial Support: Standards to Ensure the Independence of CME Activities. In accordance with these Standards, the following decisions will be made free of the control of a commercial interest: identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the CME activity.
The purpose of this policy is to ensure all potential conflicts of interest are identified and mechanisms to resolve them prior to the CME activity are implemented in ways that are consistent with the public good. The AAP is committed to providing learners with commercially unbiased CME activities.
DISCLOSURESActivity Title: Safer Health Care for Kids - Webinar Medication Safety in Ambulatory Care Activity Date: February 15, 2007
DISCLOSURE OF FINANCIAL RELATIONSHIPS All individuals in a position to influence and/or control the content of AAP CME activities are required to disclose to the AAP and subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in CME activities.
Name Name of Commercial Interest(s)*
(*Entity producing
health care goods
or services)
Nature of Relevant Financial
Relationship(s) (If yes, please list: Research Grant,
Speaker’s Bureau, Stock/Bonds
excluding mutual funds, Consultant,
Other - identify)
CME Content Will Include
Discussion/ Reference to Commercial
Products/Services
Disclosure of Off-Label (Unapproved)/Investigational Uses of Products
AAP CME faculty are required to disclose to the AAP and to learners when they plan to discuss or
demonstrate pharmaceuticals and/or medical devices that are not approved
Heather McPhillips, MD, MPH, FAAP
No No No No
Karen P. Zimmer, MD, MPH, FAAP
No No No No
DISCLOSURESSAFER HEALTH CARE FOR KIDS - PROJECT ADVISORY COMMITTEE AND STAFF DISCLOSURE OF FINANCIAL RELATIONSHIPS All individuals in a position to influence and/or control the content of AAP CME activities are required to disclose to the AAP and subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in CME activities.
Name Name of Commercial Interest(s)*
(*Entity producing health care goods
or services)
Nature of Relevant Financial Relationship(s)
(If yes, please list: Research Grant, Speaker’s
Bureau, Stock/Bonds excluding mutual funds,
Consultant, Other - identify)
CME Content Will Include Discussion/
Reference to Commercial Products/Services
Disclosure of Off-Label (Unapproved)/Investigational Uses
of Products AAP CME faculty are required to
disclose to the AAP and to learners when they plan to discuss or
demonstrate pharmaceuticals and/or medical devices that are not approved
Karen Frush, MD, FAAP (PAC Member)
No No No No
Uma Kotagal, MD, MBBS, MSc, FAAP (PAC Member)
No No No No
Christopher Landrigan, MD, MPH, FAAP (PAC Member)
No No No No
Marlene R. Miller, MD, MSc, FAAP (PAC Chair)
No No No No
Paul Sharek, MD, MPH. FAAP (PAC Member)
No No No No
Erin Stucky, MD, FAAP (PAC Member)
No No Not sure No
Nancy Nelson (AAP Staff) No No No No
Melissa Singleton, MEd (Project Manager – AAP Consultant)
No No No No
Junelle Speller (AAP Staff) No No No No
Linda Walsh, MAB (AAP Staff)
No No No No
DISCLOSURESAAP COMMITTEE ON CONTINUING MEDICAL EDUCATION (COCME) DISCLOSURE OF FINANCIAL RELATIONSHIPS All individuals in a position to influence and/or control the content of AAP CME activities are required to disclose to the AAP and subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in CME activities.
Name Name of Commercial Interest(s)*
(*Entity producing health care goods
or services)
Nature of Relevant Financial Relationship(s)
(If yes, please list: Research Grant, Speaker’s
Bureau, Stock/Bonds excluding mutual funds,
Consultant, Other - identify)
CME Content Will Include Discussion/
Reference to Commercial Products/Services
Disclosure of Off-Label (Unapproved)/Investigational Uses
of Products AAP CME faculty are required to
disclose to the AAP and to learners when they plan to discuss or
demonstrate pharmaceuticals and/or medical devices that are not approved
Ellen Buerk, MD, FAAP
No No No No
Meg Fisher, MD, FAAP
No No No No
Robert A. Wiebe, MD, FAAP
No No Not sure No
Jack Dolcourt, MD, FAAP
No No No No
Thomas W. Pendergrass, MD, FAAP
No No No No
Beverly P. Wood, MD, FAAP No No No No
CME CREDIT
The American Academy of Pediatrics (AAP) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The AAP designates this educational activity for a
maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
This activity is acceptable for up to 1.0 AAP credit. This credit can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Fellows of the American Academy of Pediatrics.
OTHER CREDIT
This webinar is approved by the National Association of Pediatric Nurse Practitioners (NAPNAP) for 1.2 NAPNAP contact hours of which 1.0 contain pharmacology (Rx) content. The AAP is designated as Agency #17. Upon completion of the program, each participant desiring NAPNAP contact hours should send a completed certificate of attendance, along with the required recording fee ($10 for NAPNAP members, $15 for nonmembers), to the NAPNAP National Office at 20 Brace Road, Suite 200, Cherry Hill, NJ 08034-2633.
The American Academy of Physician Assistants accepts
AMA PRA Category 1 Credit(s)TM from organizations accredited by the ACCME .
Heather McPhillips, MD, MPH, FAAPAssistant Professor and Associate Residency DirectorDept. of Pediatrics, University of WashingtonChildren’s Hospital and Regional Medical CenterSeattle, Washington
Medication Safety in Ambulatory Pediatrics
Heather McPhillips, MD, MPH
University of Washington, Department of Pediatrics
Funding Source:
Agency for Healthcare Quality and Research
Collaborators:
Robert Davis, Christopher Stille, Marlene Miller, Rainu Kaushal, Dave Smith, John Pearson, John Stull, Susan Andrade, Jerry
Gurwitz &
The HMO Research Network CERT
Objectives
• Epidemiology of medication errors in ambulatory care What do we know about medication errors in children
specifically in the outpatient setting?
• Known risk factors for medication errors What are barriers to error-free prescribing to children? Which children are at highest risk for errors?
• Strategies to reduce or eliminate medication errors in ambulatory settings What is known and where does future work need to focus?
Medication Safety in Children
• Children are seen by physicians often and receive medication in up to 60% of these visits.
• Medication errors are common and can occur at any step in the process Prescribing errors (dose, drug, allergy) Dispensing errors (formulation, instructions) Administration errors (dose, timing, others)
Objective #1
• Epidemiology of medication errors in ambulatory care What do we know about medication errors in children
specifically in the outpatient setting?
• Known risk factors for medication errors What are barriers to error-free prescribing to children? Which children are at highest risk for errors?
• Strategies to reduce or eliminate medication errors in ambulatory settings What is known and where does future work need to focus?
Medication Errors in the ED
Kozer et al (Pediatrics, 2002)
• Retrospective review of medication errors in charts during 12 randomly selected days in emergency department
• Prescribing errors in 10% of charts Only counted errors 20% or more outside of dosing range Analgesics, antibiotics, antihistamines, asthma drugs most
likely involved Highest risk in trainees at beginning of year and seriously ill
patients
Sedation Errors
Cote et al (Pediatrics, 2000)
• Examined 95 adverse sedation events (ASEs) 2/3 resulted in death or permanent injury
• Sedation for dental procedures accounted for 32 ASEs
• Medication overdoses, multiple sedatives, improper administration and inadequate monitoring contributed to serious errors
• Nearly ½ ASEs occurred outside the hospital setting (home, dental office, clinic, car)
Administration Errors
• Errors in administration of medications to children by their caregivers are common As few as 30% of parents correctly administer proper dose
of acetaminophen to their child Even when parents provided with correct dosing information
and child’s weight, correct dose given 40% of the time
• Frush et al (Archives of Pediatrics, 2004): Significantly less error associated with simplified color-coded information sheet and color-coded dosing syringe 50% conventional vs 92% color-coded given correct dose
Outpatient Chemotherapy for ALL
Taylor et al (Cancer, 2006)
• Reviewed chemotherapy at clinic visit over two-month period for 69 patients prescribed 172 drugs
• Identified 17 medication errors in 13 children (19%)
• Administration errors were most common, followed by prescribing errors
Potential Ambulatory Dosing Errors
McPhillips et al (Journal of Pediatrics, 2005)
• Examined potential dosing errors in new outpatient prescriptions for 22 common medications at 3 HMOs
• Potential dosing errors occurred in 280 of 1,933 (15%) of prescriptions 8% potentially overdosed 7% potentially underdosed
Dosing Variation Mg/Kg/Day(Children < 35kg, N = 1,050 Dispensings)
Class of Drug %RDD %< MinRDD %>MaxRDD
Total 67 21 12
Analgesics 79 3 18
Asthma/Allergy 57 26 17
Behavioral 59 25 16
Antibiotics 81 16 4
Anti-epileptics 70 27 3
McPhillips et al, Journal of Pediatrics, 2005
Objective #2
• Epidemiology of medication errors in ambulatory care What do we know about medication errors in children
specifically in the outpatient setting?
• Known risk factors for medication errors What are barriers to error-free prescribing to children? Which children are at highest risk for errors?
• Strategies to reduce or eliminate medication errors in ambulatory settings What is known and where does future work need to focus?
Challenges in Pediatric Prescribing
1. Pediatric prescribing is complex
2. Off-label medication use is common
3. Lack of standardization of recommended doses
4. Lack of guidelines regarding use of adult dosing regimens
Prescribing is Complex
(1) An accurate weight must be obtained and correctly transcribed (pounds or kilograms)
(2) In the course of a brief visit, the prescriber then must:• convert pounds to kilograms• make rapid weight-based calculations to determine daily
dose • divide daily dose into multiple doses to obtain the
appropriate frequency for the medication• choose the correct preparation and concentration (liquid,
chewables, tablets) of the medicine• Determine the amount of liquid/tablet to be taken for
individual dose
Prescribing is Complex
(3) Communication with the parent or caregiver often will
occur without the medication present
(4) The prescription must be legible and correctly interpreted
by the pharmacist
(5) The pharmacist must dispense the appropriate
medication in its appropriate formulation labeled with the
appropriate dose and frequency.
Off-label Prescribing is Common
• Top 100 drugs dispensed to 2 million HMO members (HMO Research Network CERT) 40 have no labeling for children 32 have some labeling restrictions
• Study examining prevalence of off-label use (1999-2001) 13% of children <17 years dispensed off-label medication 25% of children <2 years dispensed off-label medication
• Off-label medications increase risk of Adverse Drug Events (ADEs)
• Less information available about appropriate doses—less standardization
Recommended Doses Can Differ
Source Recommended pediatric dose for oxycodone
Harriet Lane Handbook 0.2 to 0.9 mg/kg/day q 4-6 hours
HMO Formulary No weight-based dose provided.
Children’s Hospital Formulary
0.2 to 1.6 mg/kg/day q 3-4 hours
No Clear Rules about Adult Dosing
• No standard for when to switch from weight-based dosing (pediatric) to daily dosing (adult)
• Some medications provide both weight-based and age-based dosing (how do you choose?)
• Difficult to determine potential errors
• Unclear if clinically relevant
For example: amoxicillin
6 year-old 40kg male with otitis failed conservative therapy
Dr. Smart would like to treat with 90 mg/kg/day divided bid
Appropriate pediatric dose:
3600 mg/day (1800mg bid)
Appropriate adult dose:
2000 mg/day (1000 bid)
Potential overdose?? Potential underdose??
Risky Situations
Medications Prone to Error(N = 2,028 Dispensings)
Class of DrugClass of Drug % RDD% RDD % UD % UD % OD% OD
Total 87 6 7
Analgesics 86 prn 14
Asthma/Allergy 89 prn 11
Behavioral 88 5 7
Antibiotics 86 12 2
Anti-epileptics 80 20 1
McPhillips et al, Journal of Pediatrics, 2005
Children at Risk for Potential OD
Characteristic Odds Ratio (95 CI)*
Age 0 to 3 years 1.6 (1.1 to 2.5)
Male 1.7 (1.1 to 2.4)
1 to 4 additional meds 1.4 (1.0 to 2.0)
5 or more additional meds 3.4 (1.4 to 8.0)
No clinic visit 1.8 (1.3 to 2.6)
*Adjusted for HMO, class of drug
McPhillips et al, Journal of Pediatrics, 2005
Objective #3
• Epidemiology of medication errors in ambulatory care What do we know about medication errors in children
specifically in the outpatient setting?
• Known risk factors for medication errors What are barriers to error-free prescribing to children? Which children are at highest risk for errors?
• Strategies to reduce or eliminate medication errors in ambulatory settings What is known and where does future work need to focus?
Computerized Prescribing for Children: Will it reduce error?
• CPOE may prevent substantial errors in children in inpatient settings (ICU), but most systems are currently home-grown
• Little is known about effectiveness in ambulatory settings
• Few commercial systems have “standard” pediatric decision support
% Within
RDD % UD % OD
% Potential Error
HMO with CPOE
(N= 1,033) 88 4 8 12
HMOs with hand-written prescriptions
(N=994)
86 8 6 14
Can CPOE Prevent Errors?
McPhillips et al, Journal of Pediatrics, 2005
Conclusions
• Medication errors are common in ambulatory pediatrics and dispensing and prescribing errors are most common.
• Higher risk prescribing situations include young children children who have not been seen in clinic multiple medications at one time “prn” medications (analgesics, asthma meds)
• CPOE without decision support may not reduce medication dosing errors in children.
Implications/Future Studies
• Electronic prescribing is a potentially successful strategy but NOT without pediatric decision support Evidence in inpatient settings that CPOE reduces
medication dosing errors
• Complexity of pediatric prescribing leads to complexity in designing electronic systems
• Simplified dosing regimens and standardization of medication doses is needed
ReferencesKozer E, Scolnik D, Macpherson A, Keays T, Shi K, Luk T, Koren
G. Variables associated with medication errors in pediatric emergency medicine. Pediatrics. 2002 Oct;110(4):737-42.
Kozer E, Scolnik D, MacPherson A, Rauchwerger D, Koren G. Using a preprinted order sheet to reduce prescription errors in a pediatric emergency department: a randomized, controlled trial. Pediatrics. 2005 Dec;116(6):1299-302.
Cote CJ, Karl HW, Notterman DA, Weinberg JA, McCloskey C. Adverse sedation events in pediatrics: analysis of medications used for sedation. Pediatrics. 2000 Oct;106(4):633-44.
Li SF, Lacher B, Crain EF. Acetaminophen and ibuprofen dosing by parents. Pediatr Emerg Care. 2000 Dec;16(6):394-7.
References
Simon HK, Weinkle DA. Over-the-counter medications. Do parents give what they intend to give? Arch Pediatr Adolesc Med. 1997 Jul;151(7):654-6.
Frush KS, Luo X, Hutchinson P, Higgins JN. Evaluation of a method to reduce over-the-counter medication dosing error. Arch Pediatr Adolesc Med. 2004 Jul;158(7):620-4.
Taylor JA, Winter L, Geyer LJ, Hawkins DS. Oral outpatient chemotherapy medication errors in children with acute lymphoblastic leukemia. Cancer. 2006 Sep 15;107(6):1400-1406.
References
McPhillips HA, Stille CJ, Smith D, Hecht J, Pearson J, Stull J, Debellis K, Andrade S, Miller M, Kaushal R, Gurwitz J, Davis RL. Potential medication dosing errors in outpatient pediatrics. J Pediatr. 2005 Dec;147(6):761-7.
Gandhi TK, Weingart SN, Seger AC, Borus J, Burdick E, Poon EG, Leape LL, Bates DW. Outpatient prescribing errors and the impact of computerized prescribing. J Gen Intern Med. 2005 Sep;20(9):837-41.
Karen P. Zimmer, MD, MPH, FAAPAssistant ProfessorJohns Hopkins UniversityBaltimore, Maryland
Epidemiology and Intervention for Pediatric Ambulatory
Medication Errors Karen P. Zimmer, MD, MPH
Marlene R. Miller, MD, MSc
February 15, 2007
Safer Health Care for Kids Webinar
“Medication Safety in Ambulatory Care”
Goals
• Background• Epidemiology
Example: Analysis of a National Voluntary Database (MEDMARX Database)
• Suggestions for Addressing Medication Errors• Process Improvement
Example: Narcotic Prescription Writer
Background on Medication Errors
• Most common adverse eventIOM, 2000; Bates 1995
• Most error prone step is prescribingLesar TS, 2002; Errors DB, 1999
• Most errors occur as a result of both individual and system failures
Leape LL et al. 1995; Reason J, 2000
• Competent staff make mistakes
National Reporting System: United States Pharmacopeia MEDMARX
• United States Pharmacopeia (USP) A practitioner-based organization that sets standards for
identity, strength, quality, purity, packaging, labeling, and storage of therapeutic products.
• MEDMARX Database National, voluntary, internet-accessible error reporting
system Consists of 616 subscribing hospitals since January, 2005 All are US hospitals All 50 states are represented
Study on Epidemiology
• Objective: To characterize and understand medication errors in the outpatient clinic settings What types of medication errors occur? Where in the process do errors occur? What harm occurs?
MEDMARX
• Error reporting System Standardized Provides information on prescriptions as well as
medications in all types of ambulatory clinics• Error timing• Unit location• Phase of care in which error occurred• Error category• Cause of error• Medication Involved
MEDMARX Analysis• Inclusion Criteria
Queried database for all error reports from 2003 and 2004
Involving patients < 19 years of age In all outpatient clinics (general and specialty clinics) Error category limited to harm scores of Category C-I
(medical errors that reached the patient).
Results: All Errors
• Medication error reports (N=566) Involved 636 products (medications)
• Number of participating institutions 154 (2003) and 162 (2004)
• Clinic-Type Distribution General Community Hospital Affiliate (52%) Stand alone Outpatient Clinic (28%) University Hospital Affiliate (11%)
• Age distribution Greatest for ages 1-3 (25.1%) and 12-18 (24.7%)
Results: All Errors
• Harm Score Over 2/3 of errors reached the patient but did not
cause harm (Category C) 4% harmed the patient (Category E-I) Family/Patient discovered medication errors
almost 20% of the time.
Results: All Errors
• Error Node Definition: the phase of the medication process
where the error occurs• Administering (42%) • Prescribing phases (41%)• Dispensing (12%)• Transcribing/Documenting (4%)• Monitoring (1%)
Distribution of Error Types for All Medications
17%
14%
11% 10%
9%
7%
4% 4%3%
22%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
Imp
rop
er
do
se
/qu
an
tity
Pre
sc
rib
ing
Err
or
Un
au
tho
rize
d/w
ron
g
Do
sa
ge
Fo
rm
Dru
g p
rep
are
din
co
rre
ctl
y
Ex
tra
Do
se
Om
iss
ion
Err
or
Wro
ng
pa
tie
nt
Wro
ng
tim
e
Wro
ng
ad
min
istr
ati
on
te
ch
niq
ue
/ wro
ng
rou
te
A t
yp
e n
ot
de
term
ine
d
Results: Medications Involved
0
5
10
15
20
25
30
35
40
45Immunologic(vaccines)
Antimicrobials
CNS meds (sedatives)
Respiratory Tract(bronchodilators)
Dermatologic Agents
Hormones (Insulin)
Antihistamines
Gastrointestinal
Musculoskeletal
Therapeutic Nutrients
Ophthalmic
Otic agents
Percent
Age Distribution for Vaccines Errors
0-1 years1-3 years4-6 years7-11 years12-18 years
25.1%
24.7%
18.7%
17.0%
14.5%
Error Distribution:Top 5 Vaccines
7
9
9
10
12
0 2 4 6 8 10 12 14
Pneumococcal Conjugate Vaccine
Diphtheria, Tetanus Toxoids, Acellular PertussisAdsorbed, Hepatitis B (Recombinant), and
Inactivated Poliovirus Vaccine
Varicella Virus Vaccine Live
Influenza Virus Vaccine
Hepatitis B Vaccine, Recombinant
Vaccines: Types of Errors
8
141717
27
0
5
10
15
20
25
30
Per
cen
ts
Age Distribution for Antimicrobials Errors
0-1 years1-3 years4-6 years7-11 years12-18 years
22.7%
18.6%
24.7%
20.6%
13.4%
Antimicrobials: Distribution
7
10
12
28
0 5 10 15 20 25 30
Amoxicillin andClavulanate
Ceftriaxone
Azithromycin
Amoxicillin
Percents
Antimicrobials: Error Types
21
18
1312 12
2
17 17
8
27
11
14
0
5
10
15
20
25
30
Pe
rce
nts
Antimicrobials
Vaccines
Suggestions for Addressing Medication Errors
• Error Prevention An evaluation framework in place Error-resistant systems are better than continuous education Providing redundant checks (increasing pharmacist
availability, different methods and persons at the various stages of the medication process, 2 person, or using software and a person)
• Leveraging Technology• Standardized Practice
Lehmann CU and Kim GR, Clin Perintal 2005
Standardized Practice Preprinted order sheet in a pediatric ED reduced errors
(OR 0.55, CI 0.34-0.90)Kozer et al, Pediatrics 2005
• A modified outpatient prescription form was used to reduce prescription errors in an adult populationKenety and Littentber, Joint Commission on Accreditation of Healthcare Organizations
• Electronic prescribing in an adult, ambulatory practice improved throughput and increased patient satisfactionPapshev,et al. Am J Manag Care 2007; Adubofour K, etl al. J of National Med Assoc 2004
A Successful Intervention: Example
Methods• Method/Design
Retrospective study December 2005 to October 2006 Program implemented over several months Inpatient and outpatient settings
• Eligibility: General pediatric services and all surgical services Residents, fellows, nurse practitioners
• Narcotic prescriptions for all discharged patients from 0-18 years of age
• Users: 266 prescribers General pediatric (112, 42%) Orthopedic (38, 14%) Surgery (33, 12%
Distribution of Medications
0.1% 0.2% 0.4% 1.0% 1.4% 2.3% 2.3% 2.8% 6.0% 6.2% 7.3% 7.3%
62.7%
0.0%
20.0%
40.0%
60.0%
80.0%
Avi
nza
MS
Con
tin
Kad
ian
Per
coce
t(A
ceta
min
ophe
nw
ith O
xyco
done
Tylo
x(A
ceta
min
ophe
nw
ith O
xyco
done
)
Oxy
Con
tin
Ace
tam
inop
hen
with
Cod
eine
Tabl
et
Mor
phin
e
Met
hado
ne
Dia
zepa
m(V
aliu
m)
Hyd
rom
orph
one
Ace
tam
inop
hen
with
Cod
eine
Elix
ir
Oxy
codo
ne
Outcome of Prescription Attempts
4,995 Attempts
713 Attempts With Alerts
4,282 Attempts Without Alerts
2,942 Prescriptions1,340 Incomplete 416 Incomplete297 Overridden
3,239 Total Prescriptions
Results
• A prescription attempt with an alert was abandoned 58% of the time compared to 31% of the time if no alert were generated (p<0.001).
• Alerts resulted in statistically significant increase in
abandoned prescription attempts.
Conclusion
• Identify vulnerabilities based on commonly used medication types, age of patients and practice environment
• Support systems that highlight potential errors can alter behavior and prevent errors from being completed
Take Home Points
• Dosing errors are common in ambulatory pediatrics• Administering and prescribing are key error-prone
stages• Narcotic analgesics pose high risk of harm• Decision support is a crucial part of electronic
prescription writing systems.