Automated dosing: computerized physician order entry reduces risk of medication and dosing errors in neonatal ICU.

Computerized physician order entry (CPOE) can serve as the backbone of a hospital's patient safety initiatives especially when it comes to reducing medication errors and associated complications. Some studies have indicated that CPOE systems may help a healthcare facility reduce serious medication errors by up to 55 percent, and in crease the likelihood of more appropriate dosing.

Such reductions become especially critical in specialty units like neonatal intensive care (NICU) where even the smallest error can have significant impact, says Barry Blumenfeld, M.D., associate director for clinical informatics research and development at Chestnut Hill Mass.-based Partners HealthCare System. Brigham and Women's Hospital (BWH-), part of the Partners integrated delivery network recently implemented a CPOE sys tern in its NICU that will serve as the model for all order entry systems eventually deployed throughout the Partners network.

"You're dealing with very tiny children and therefore very tiny drug doses," Blumenfeld says. "If a dose is off by even a miniscule amount, it can cause significant damage." Because dosages are calculated in minute, precise formulations based on the infant's age and weight, that adds another layer where errors can potentially occur, according to Blumenfeld. The neonates are also administered very tightly controlled fluids and nutrients.

Tailoring the Dose

On average, BWH's NICU has 53 patients daily, or about 1,400 patients per year. There are nine full time neonatologists on staff, with three on service each month, two fellows per month, three interns assigned on a rotating basis and nine other house staff members.

The CPOE system went live or Oct. 7, 2002. In the first 30 days physicians and nurses entered 16,000 orders, and around 4,500 medication orders were checked for drug/drug interactions. The system flagged about 40 drug/drug interactions within that time frame and resulted in changes in medication therapy, Blumenfeld says. At the four-month mark, about 16,700 orders were entered each month--including approximately 5,000 medication orders. The system flagged some 72 drug/drug inter action reports.

BWH chose a Web-based program. because Internet-based access is the standard for most of Partners clinical programs. In the NICU, physicians and nurses rely on thin-client workstations, but physicians can also logon to the system from their homes or offices. A Web-based system is also easier to update and maintain than a locally housed system, according to Blumenfeld.

It was a two-year process to bring CPOE to the NICU, Blumenfeld says and hospital staff spent "enormous amounts" of time discussing the project. This included repeated refinements of order screens, discussions over how the system would work, making sure it fit appropriately with workflow and that it didn't cause redundancies or in crease the paper trail. While BWH created its own CPOE system in the NICU--as in other areas of the hospital where CPOE is long-standing--First DataBank, San Bruno, Calif., provides a drug database and some associated clinical decision support modules.

Before establishing the NICU system's drug database, a committee of pharmacists and nurses, overseen by neonatologists, scoured a long list of medications used in the unit, says Steven Ringer, M.D., director of newborn medicine. They determined the appropriate recommended doses for those drugs and turned the information over to First DataBank to help build the CPOE system's drug database. First DataBank provides BWH with a drug database that includes descriptive information about the drug (e.g., in which dose forms and strengths the drug is available) and clinical information such as decision support, allergy checking and drug/drug interaction checking. The First DataBank information is mapped to a drug dictionary BWH developed internally, Blumenfeld says.

The CPOE system "knows" which drugs need to be dosed based on the patient's weight and age, and provides users with a constrained list of drugs, explains Joan Kapusnik-Uner, Pharm.D., senior knowledge engineer at First Data Bank. The knowledge base is programmed with which formulation of the drug are available, and the user views a constrained list of appropriate clinical and dosage in formation. The system also includes the list of strengths the drug is available in; with one or two clicks, the user has an appropriate formulation that can be dispensed.

Dosing advice includes a preconstructed order sentence that is based on the patient's age and weight, Kapusnik-Uner says. The program can also provide short text descriptions that "reword" advice for ease of recognition and to enhance advice acceptance Assessment of the final dose amount is tailored to the individual patient and there are fewer mathematical errors that can occur such as misplaced decimal points or a mistyped number. The program provides input about proper administration of a particular medication such as how fast to infuse something, which lab test results might need to be monitored or which physical exam might need to be done.

Before implementing CPOE, nurse would look up the proper dose in a big book kept in the NICE "It might have last year's sheet for that drug, or someone else might have looked up the same medication and the page was gone out o the loose-leaf notebook," Ringer says. A nurse or physician would then use a calculator to figure out the appropriate dose for the neonate. There were sometimes multiplication errors or the caregiver might hit the wrong button on the calculator.

Ringer notes that computerized order entry can create a different set of potential medication errors Under a paper-based system, the physician might write the wrong dose of the medication or put a decimal point in the wrong place.

Potential for New Errors

"What I worry about now is when you see that list, what if your hand slips and you click the wrong drug?" Ringer says. "It's highly likely a mistake like that would get caught, but you run the risk of trading the types of errors that can occur."

He has also seen instances where, for example, a caregiver orders IV fluids and has a choice to enter a daily total volume or hourly volume. He or she puts the number in the wrong box, and instead of ordering 80 cc per kilogram per day, the user orders 80 cc per kilogram per hour and the system calculates it to a very high daily rate. "You get some ridiculous rate per day. The numbers are usually so far out of range that someone catches it," Ringer says. "But you still don't want to run the risk of it happening in the first place."

Currently, the medication order entry system provides a constrained list of orders on the front end, Kapusnik-Uner says. Subsequent versions will add the backend checking as well.

Gauging Success

BWH recently launched a study to determine how effectively the CPOE system boosts patient safety and conduct of care, according to Ringer. He expects that BWH will finish collecting study data by the end of November and will make the results available as soon as possible thereafter. The hospital waited until the system had been in use for a few months and staff was familiar with the order entry process before studying the number of errors the system caught. "We wanted to make sure we were not assaying errors due simply to lack of familiarity with the system," Ringer says.

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