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Computer systems prevent errors

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Comment

What is the evidence that giving healthcare professionals better tools makes them perform the complicated tasks they do better? A systematic review [1] of computer based clinical decision support systems (CDSS) shows two things. It demonstrates that there are many studies in a wide variety of different clinical areas. It shows that they work.

Search


Studies using CDSS in a clinical setting by a healthcare practitioner and assessing the effects in a prospective setting with a concurrent control were sought. Five databases, reference lists and conference proceedings were searched.

Results


Sixty-eight studies were found (Table 1). Of 15 studies of drug dosing systems, 60% found benefit. Of 19 studies on preventive care systems, 74% found benefit. Of 26 studies in other clinical areas, 73% found benefit. Only one of five diagnostic decision support systems found benefit; that used a system to identify postoperative patients at risk of respiratory complications for physiotherapy.

Table 1: Healthcare professional performance in studies of CDSS
Study area Studies showing benefit/total
Drug dosing systems 9/15
Diagnostic aids 1/5
Preventive care systems 14/19
Other medical care 19/26
All CDSS studies 43/65

Comment


The systematic review is a terrific bit of work. But the question still hanging is whether computer systems can contribute significantly to reduce adverse drug events in hospitals. Two US examples show exactly what can be achieved [2,3].

Boston


In the Brigham and Women's Hospital, which is a 726-bed tertiary referral centre, the use of a physician computer order-entry (POE) system was evaluated, in which doctors wrote all drug orders online. The study had a baseline period during which an audit of medication errors was examined, followed by implementation of the POE system and re-audit. Incidents were identified by three mechanisms: nurses and pharmacists reported incidents, an investigator visited wards twice daily to solicit information, and patient charts were examined daily by an investigator.

The main outcome was the number of nonintercepted serious medication errors. These were either an error preventable by systems currently in use, or had the potential for harm but did not result in injury.

Results


Use of the POE system prevented more than half of the serious medication errors. There were just under 11 of these per 1000 patient days at baseline, and under 5 per 1000 patient days during use of the POE system. Potential errors which had not been intercepted fell most, by 84%. Preventable errors fell by 17%.

The authors concluded that their system could be extended to different drug types, like sedatives, which actually rose, which had not been included in their original system, and by extending the system in other ways. They also show that the cost of running a POE system for their large, complicated, hospital, would be of the same order as money saved directly. When other costs, like extra work caused by serious drug errors, or malpractice litigation, were included, it could save $5-10 million a year. The system could both save money and improve quality of care.

Phoenix


The Good Samaritan Regional Medical Centre in Phoenix is a 650-bed referral centre. It has an integrated hospital information system. A multidiciplinary team of professionals met and identified 37 drug or class-specific areas where adverse drug events might be expected. The system was modified so that if circumstances arose where an adverse drug event might occur (digoxin toxicity was one example), then a pharmacist or radiologist was alerted. If necessary, the physician attending the patient was contacted.

Results


Over six months there were 9306 non-obstetric admissions. There were 1116 alerts (Table 2). Physicians needed to be contacted 794 times, and 596 times the event had not been recognised. The average time taken for each contact was 15 minutes.

Table 2: Adverse drug event alerts
Event Number per 1000 admissions Percent
Nonobstetric admissions 9306    
ADE alerts 1116 120 100
Evaluator needed to alert physician 794 85 71
True potential adverse drug events 596 64 53
Physicians unaware of potential for harm 265 28 24
Changes in treatment 265 28 24

The rates of clinically unrecognised events varied for different clinical circumstances. For instance, more than half of the potential problems for renal toxicity with the use of radiocontrast media had been previously recognised, but it was felt that potential benefit outweighed potential harm.

Using some literature data on costs, the authors calculated that the potential saving to their 650-bed hospital was some $3 million a year, and could be more if the system were extended to other areas.

Comment


These are two different types of interventions. One depends on putting systems in place to stop mistakes happening. The other depends on real-time interventions to stop mistakes when they happen. Both had a major effect in stopping medication errors in large, complex institutions. Both would improve patient care. Both would reduce costs.

Concentrating on stopping bad things happening is what quality control is all about. These are two excellent examples of how to do it. Moreover, all three papers have extensive referencing of a wealth of literature in this area, and are worth reading for that alone.

Reference:

  1. DL Hunt, RB Haynes, SE Hanna, K Smith. Effects of computer-based clinical decision support systems on physician performance and patient outcomes. JAMA 1998 280: 1339-1346.
  2. DW Bates et al. Effect of computerized physician order entry and a team intervention on prevention of serious medical errors. JAMA 1998 280: 1311-1316.
  3. RA Raschke et al. A computer alert system to prevent injury from adverse drug events. Development and evaluation in a community teaching hospital. JAMA 1998 280: 1317-1320.
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