Transition to a new electronic health record and pediatric medication safety: lessons learned in pediatrics within a large academic health system

Whalen, Kimberly; Lynch, Emily; Moawad, Iman; John, Tanya; Lozowski, Denise; Cummings, Brian

doi:10.1093/jamia/ocy034

Cited by 40 publications

(49 citation statements)

References 16 publications

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“…For example, errors in the configuration of prescribing templates may be 'automatically incorporated into otherwise error-free prescriptions' (Aita et al, 2013). Comprehensive EMM systems for chemotherapy protocols are challenging to implement, both in adult and paediatric settings (Martin, Kaemingk, Frieze, Hendrie, & Payne, 2015;Whalen et al, 2018). They require time-dependent, patient-specific dosing functions based on factors such as age, weight and surface area (highly variable over a child's course of treatment), organ function, as well as functionalities for scheduling and timing of interdependent medications and supportive care.…”

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confidence: 99%

Medication safety incidents in paediatric oncology after electronic medication management system implementation

et al. 2019

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Objective To explore medication safety issues related to use of an electronic medication management system (EMM) in paediatric oncology practice, through the analysis of patient safety incident reports. Methods We analysed 827 voluntarily reported incidents relating to oncology patients that occurred over an 18‐month period immediately following implementation of an EMM in a paediatric hospital in Australia. We identified medication‐related and EMM‐related incidents and carried out a content analysis to identify patterns. Results We found ~79% (n = 651) of incidents were medication‐related and, of these, ~45% (n = 294) were EMM‐related. Medication‐related incidents included issues with: prescribing; dispensing; administration; patient transfers; missing chemotherapy protocols and information on current stage of patient treatment; coordination of chemotherapy administration; handling or storing medications; children or families handling medications. EMM‐related incidents were classified into four groups: technical issues, issues with the user experience, unanticipated problems in EMM workflow, and missing safety features. Conclusions Incidents reflected difficulties with managing therapies rich in interdependencies. EMM, and especially its ‘automaticity’, contributed to these incidents. As EMM impacts on safety in such high‐risk settings, it is essential that users are aware of and attend to EMM automatic behaviours and are equipped to troubleshoot them.

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Medication safety incidents in paediatric oncology after electronic medication management system implementation

et al. 2019

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“…Computerized provider order entry (CPOE) systems with decision support are a further strategy for improving safety with chemotherapy. CPOE can reduce medication errors and unwanted protocol deviations by automatically calculating chemotherapy doses based on patient height and weight, providing warnings, assisting in scheduling of chemotherapy cycles, and supporting workflow [10][11][12][13][14][15][16]. Conversely, CPOE can introduce new types of error and have unexpected negative consequences on work practices [1,17].…”

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confidence: 99%

Electronic ordering and the management of treatment interdependencies: a qualitative study of paediatric chemotherapy

Lichtner

Franklin

Dalla‐Pozza

et al. 2020

BMC Med Inform Decis Mak

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Background: There are serious safety risks associated with chemotherapy, often associated with interdependencies in regimens administered over months or years. Various strategies are used to manage these risks. Computerized provider order entry (CPOE) systems are also implemented to improve medication safety. Little is known regarding the effect of CPOE on how clinicians manage chemotherapy interdependencies and their associated safety strategies. Methods: We conducted a multi-method qualitative study in a paediatric hospital. We analysed 827 oncology incidents reported following CPOE implementation and carried out semi-structured interviews with doctors (n = 10), nurses (n = 6), a pharmacist, and oncology CPOE team members (n = 2). Results were interpreted according to safety models (ultra-safe, high-reliability organisations [HROs], or ultra-adaptive). Results: Incident reports highlighted two interrelated types of interdependencies: those within organisation of clinical activities and those inherent in chemotherapy regimens. Clinicians reported strategies to address chemotherapy risks and interdependencies. These included rigid rules and 'no go' contexts for treatment to proceed, typical of the ultra-safe model; use of time (e.g. planning only so far ahead) and sensitivity to operations, typical of HROs. We identified three different time horizons in CPOE use in relation to patients' treatments: lifelong , the whole regimen, and the 'here and now'. CPOE supported ultra-safe strategies through automation and access to rules/standardisation, but also created difficulties and contributed to incidents. It supported the 'here and now' better than a lifelong or whole regimen view of a patient treatment. Sensitivity to operations was essential to anticipate and resolve uncertainties, hazards, CPOE limitations, and mismatches between CPOE processes and workflow in practice.

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Section: Introductionmentioning

confidence: 99%

“…Conversely, CPOE can introduce new types of error and have unexpected negative consequences on work practices (1,17). It can also be challenging to implement CPOE for chemotherapy (15,16,18,19), with every chemotherapy protocol having to be entered in the system and then kept up to date (15,20).…”

Section: Introductionmentioning

confidence: 99%

Electronic ordering and the management of treatment interdependencies: a qualitative study of paediatric chemotherapy

Lichtner

Franklin

Dalla‐Pozza

et al. 2020

Preprint

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Background: There are serious safety risks associated with chemotherapy, often associated with interdependencies in regimens administered over months or years. Various strategies are used to manage these risks. Computerized provider order entry (CPOE) systems are also implemented to improve medication safety. Little is known regarding the effect of CPOE on how clinicians manage chemotherapy interdependencies and their associated safety strategies.Methods: We conducted a multi-method qualitative study in a paediatric hospital. We analysed 827 oncology incidents reported following CPOE implementation and carried out semi-structured interviews with doctors (n=10), nurses (n=6), a pharmacist, and oncology CPOE team members (n=2). Results were interpreted according to safety models (ultra-safe, high-reliability organisations [HROs], or ultra-adaptive). Results: Incident reports highlighted two interrelated types of interdependencies: those within organisation of clinical activities and those inherent in chemotherapy regimens. Clinicians reported strategies to address chemotherapy risks and interdependencies. These included rigid rules and ‘no go’ contexts for treatment to proceed, typical of the ultra-safe model; use of time (e.g. planning only so far ahead) and sensitivity to operations, typical of HROs. We identified three different time horizons in CPOE use in relation to patients’ treatments: life-long, the whole regimen, and the ‘here and now’. CPOE supported ultra-safe strategies through automation and access to rules/standardisation, but also created difficulties and contributed to incidents. It supported the ‘here and now’ better than a life-long or whole regimen view of a patient treatment. Sensitivity to operations was essential to anticipate and resolve uncertainties, hazards, CPOE limitations, and mismatches between CPOE processes and workflow in practice. Conclusions: Within oncology, CPOE appears to move the ‘mix’ of risk strategies towards ultra-safe models of safety and protocol-mandated care. However, in order to operate ultra-safe strategies embedded in CPOE and stay on protocol it is essential for clinicians to be thoughtful and show sensitivity to operations in CPOE use. CPOE design can be advanced by better consideration of mechanisms to support interdependencies.

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Transition to a new electronic health record and pediatric medication safety: lessons learned in pediatrics within a large academic health system

Abstract: Future research and work need to be focused on standards and guidelines on implementing an EHR that encompasses all age contexts.

Cited by 40 publications

References 16 publications

Medication safety incidents in paediatric oncology after electronic medication management system implementation

Medication safety incidents in paediatric oncology after electronic medication management system implementation

Electronic ordering and the management of treatment interdependencies: a qualitative study of paediatric chemotherapy

Electronic ordering and the management of treatment interdependencies: a qualitative study of paediatric chemotherapy

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