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Implementation project
The implemented CPOE system was PANDAWebRx,26 a web application developed by CGSI@SOLUTIONS-TI in collaboration with the hospital project team (one clinical informatics manager and two full-time project managers). A previous usability analysis conducted a month before the implementation revealed the need to optimise the clinical decision support system (CDSS) to identify inappropriate dosing instructions for paediatric patients,27 which is also known to be a recommended practice in the Safety Assurance Factors for EHR Resilience(SAFER) Guides.28 The implementation process lasted more than a year (online supplemental figure 1). Order sets were developed by a team of clinicians on the paediatric unit to standardise the ordering process and ensure that they were adapted to the clinical workflows. Pilot testing occurred at each workstation during the summer of 2019 for periods of 48 hours. In the month prior to the Go-live, all physicians, nurses and other providers on the unit were required to complete online training modules (30–90 min), followed by in-classroom order scenario testing (60 min).
The Go-live occurred on 21 October 2019. On-site and phone line support was provided 24/7 for 4 months. Although the entire unit switched to electronic prescriptions, some rare paper prescriptions were still written in the first months following the Go-live. These paper prescriptions occurred when the prescriber, most often from another specialty, would want to prescribe using a specific formulary and had difficulty doing so with the electronic format. As of August 2021, the CPOE has been implemented in other hospital units.
Description of the CPOE system
Previous versions of PANDAWebRx were used to prescribe drugs in adult settings. The new version was adapted for paediatric prescribing (eg, paediatric order sets). However, the system did not include paediatric dose range checking or other paediatric specific alerts since the development of a paediatric CDSS represented a separate feature that was not developed during the first phase of the CPOE implementation. However, the CPOE system integrated a CDSS (RxVigilance by Vigilance Santé) for allergies and drug–drug interactions alerts, which is deactivated by default and is interfaced directly with the hospital’s PIS and eMAR. Figure 1 shows the screenshots of the CPOE and eMAR modules. The CPOE was designed by following many of the recommendations in the SAFER Guides to prevent unwanted consequences, as detailed in the online supplemental table 1.
PANDAWebRx (Aa) CPOE view and (Bb) eMAR view. In the CPOE view, the provider can choose to group orders by type of orders (medication, nutrition, surveillance, imaging, etc.) or by protocol. Critical information for prescribing (weight, allergies, kidney function) is displayed on the top panel. CPOE, computerised provider order entry; eMAR, electronic medication administration record.
Description of the medication management process
Based on a content analysis of the non-participant observation notes, project documents and discussions, we identified that the medication management process was significantly revised for the CPOE implementation (online supplemental table 2). Significant changes occurred for the ordering and acknowledgement, transmission and transcribing steps. Nurses were no longer tasked with scanning and transmitting the prescription to the pharmacy department. Furthermore, nurses acknowledged new prescriptions electronically and would import the CPOE data to the eMAR without manual transcription. Similarly, in the pharmacy department, pharmacy technicians would import the order information instead of manually transcribing the orders. After importing the CPOE data into the PIS, the pharmacy technicians would complete the order with other required information (eg, dispensed drug product, pharmacy comments).
Medication errors
A total of 133 and 109 medication-related accidents and incidents were reported during the pre-implementation and post implementation periods, respectively. Medication-related errors in the paediatric unit represented 31% (133/429) and 23% (109/466) of all types of medical incidents/accidents in pre-implementation and post implementation periods, respectively. There were no statistically significant differences when comparing the proportions for the drug categories, drug routes, time of incident/accident or severity, except for a difference in reports related to drugs with buccal administration and errors with a severity level of A (online supplemental table 3). The majority of the reports were adverse events that did not lead to any patient consequence (72% and 73% of the reports in preperiods and postperiods, respectively). A similar analysis conducted to evaluate the effect of the COVID-19 pandemic by comparing reports from the first 6 months of the pandemic (March to October 2020) with the same period a year before revealed no differences for all variables.
Most of the medication errors occurred during the nurse administering step (step 4) (table 1). The rate ratios for each step were not significant, except for the order acknowledgement, transmission and transcribing steps (step 2; rate ratio: 4.4, 95% CI 1.1 to 32.5), which represented the second most common type of errors in the pre-implementation period. Overall, there is a slight, but not significant, reduction in the total number of medication errors between the two periods (rate ratio: 1.2, 95% CI 0.8 to 1.7). Medication errors during the ordering step (step 1) did not decrease after the CPOE implementation (rate ratio: 0.9, 95% CI 0.2 to 3.7).
Number and rate of medication errors at each step of the medication management process before and after the CPOE implementation
Examples of medication errors during both periods are presented in table 2 and grouped by the stage of the medication management process. There were notable differences between the types of errors occurring before and after the CPOE implementation, primarily at the ordering (step 1) and acknowledgement, transmission and transcribing (step 2) steps (table 1), which correlates with the considerable changes at these steps in the medication management process (online supplemental table 2).
Examples of errors identified at each step in the inpatient medication management process before and after the CPOE implementation
At the ordering stage, the CPOE standardised mandatory steps (eg, required countersignature for orders from external consultants) (example 1) and formalised steps that were previously not electronically documented (example 5). Furthermore, although the CPOE was designed to enable all possible order scenarios, some orders were prescribed on paper (example 4), which delayed the order. At the acknowledgement, transmission and transcribing steps, the electronic transmission of orders ensured that there were no transmission errors (example 9), and that the order information was correctly entered in the other systems (examples 10 and 11). Types of errors that were common to both periods occurred most frequently at the nurse administering stage, specifically during the preparation of the order. These include the preparation of orders with the wrong dose or wrong frequency, as well as documentation errors (examples 21, 22 and 25).
Lastly, although some examples were only reported during one of the two periods, these errors might not be related to the use (or lack of) of the CPOE. Instead, some examples could be due to other factors, such as technical factors (eg, eMAR usability: examples 19 and 20), human factors (eg, staff’s knowledge and skill: example 27) or organisational factors (eg, structure, culture, processes: examples 13, 16 and 17).
Recommendations for preventing medication errors
A total of 232 and 199 recommendations were extracted from the medication error reports and categorised based on the proposed taxonomy by Franklin et al21 (table 3). The most frequent types of recommendation during both periods were vigilance (eg, always make sure to check the patient’s eMAR carefully), counselling (eg, met with the nurse to review event) and education/training of healthcare workers (eg, redo training on diabetes, event discussed during 5 min staff huddles), which are person-based approaches. There were few system-based approaches (eg, speaking with the pharmacy department to ensure that medication orders with irregular frequency are prepared accordingly).
Event review approaches and specific categories with frequency counts and percentages before and after the CPOE implementation
On the total of 133 and 109 drug errors reported in the pre-implementation and post implementation periods, respectively, two pharmacists reviewed all reports and identified potential HIT-related prevention strategies for 85 (64%) and 64 (59%) of the pre-implementation and post implementation error reports. The remaining error reports were mainly associated with human and organisational factors and no technology-related prevention strategies were identified (table 4).
Potential HIT-related prevention strategy identified for all medication errors before and after the CPOE implementation
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