Difference between revisions of "Comprehensive Analysis of a Medication Dosing Error Related to CPOE"

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Understanding the acuity of users at crucial stages of an incident that occurred during the use of CPOE is extremely beneficial to the process of characterizing cognitively based errors.
 
Understanding the acuity of users at crucial stages of an incident that occurred during the use of CPOE is extremely beneficial to the process of characterizing cognitively based errors.
 
In this article, the case of a serious medication error that occurred at a large academic medical institution is described and a synopsis of how the error was analyzed is discussed. The authors hope that characterization of the entire process of the error will provide key insight and recommendations for improving CPOE systems and clinical ordering procedures.
 
In this article, the case of a serious medication error that occurred at a large academic medical institution is described and a synopsis of how the error was analyzed is discussed. The authors hope that characterization of the entire process of the error will provide key insight and recommendations for improving CPOE systems and clinical ordering procedures.
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 +
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==Case Description==
 +
*An elderly man was admitted to a medical intensive care unit with septic shock and respiratory failure then transferred to a pulmonary service unit.
 +
*On a Saturday morning, Provider A diagnosed the patient as hypokalemic after observing a low serum KCL in the setting of renal insufficiency.
 +
*Provider A decided to replete the patient’s KCL by providing 40 mEq of KCL via an IV route over a period of 4 hours as indicated by institutional guidelines.
 +
*After the order was entered, Provider A realized that the patient already had an IV fluid line and subsequently decided to provide KCL as an additive to the currently running IV fluid.
 +
*Provider A then entered a new order for infusion of 100 mEq of KCL in 1 liter of D5W solution at a rate of 75ml/hr.
 +
*The order for 40 mEq of KCL through IV was supposed to be discontinued at this point but Provider A mistakenly discontinued a similar order entered by another clinician from two days earlier.
 +
*Provider A then received notification from the pharmacy department that the dose of 100 mEq of KCL in 1 liter of D5W was higher than the maximum allowed for the facility.
 +
*Provider A discontinued the order for 100 mEq of KCL in 1 liter of D5W and wrote a new order for 80mq/L KClr.
 +
*This new order for 80mq/L KClr was supposed to deliver 1L of fluid however the order did not specify stop time or maximum volume of fluid to be delivered.
 +
*As a result, the fluid continued to be administered for 36 hours. Unfortunately, Provider A unintentionally caused the patient to receive a total of 256 mEq KCL over 36 hours.
 +
*On Sunday morning, there was a change in coverage. Provider A asked Provider B to check the patient’s KCl level.
 +
*Provider B reviewed the patient’s most recent serum KCl which was taken on Saturday morning (before the infusion of potassium). The value was 3.1 mEq/ L which indicated that the patient was hypokalemic. Provider B did not  realize that the lab result was indicative of the patient’s potassium status prior to unnecessary KCl repletion.
 +
*Provider B then ordered 60mEq KCl by injection to be given even while the previous potassium drip was still running.
 +
*Order entry logs revealed that another dose of 40mEq KCl IV injection was also ordered by Provider B but no clear evidence from sources indicate that it was actually given.
 +
*Therefore, the patient received a total volume of 316 mEq KCl over 42 hours.
 +
*On Monday, when the patient’s potassium levels were checked, the patient was found to be dangerously hypokalemic with a serum potassium level of 7.8 mEq/L.
 +
*Once the errors were discovered, immediate measures were taken and the patient was treated.

Revision as of 20:58, 4 November 2015

This is a systematic review of the article entitled “Comprehensive Analysis of a Medication Dosing Error Related to CPOE” by Jan Horsky [1].


Introdution

New drugs that manage or relieve previously untreated diseases have come about due to new innovations in pharmacology research. These advancements in drug therapy have led to increased incidence of Adverse drug event (ADEs) due to avoidable causes such as prescribing errors. Computerized physician order entry (CPOE) systems are known to drastically minimize the incidence of ADEs by confirming legibility of orders and integrating clinical decision support (CDS) such as checking for allergies.

However, the progressive effect of CPOE on prescribing safety can be compromised by the advent of new forms of errors. These errors are related to the intricacy of the human-computer interaction and may be a consequence of poor user training or inadequate understanding of data handling by a CPOE application.

Understanding the acuity of users at crucial stages of an incident that occurred during the use of CPOE is extremely beneficial to the process of characterizing cognitively based errors. In this article, the case of a serious medication error that occurred at a large academic medical institution is described and a synopsis of how the error was analyzed is discussed. The authors hope that characterization of the entire process of the error will provide key insight and recommendations for improving CPOE systems and clinical ordering procedures.


Case Description

  • An elderly man was admitted to a medical intensive care unit with septic shock and respiratory failure then transferred to a pulmonary service unit.
  • On a Saturday morning, Provider A diagnosed the patient as hypokalemic after observing a low serum KCL in the setting of renal insufficiency.
  • Provider A decided to replete the patient’s KCL by providing 40 mEq of KCL via an IV route over a period of 4 hours as indicated by institutional guidelines.
  • After the order was entered, Provider A realized that the patient already had an IV fluid line and subsequently decided to provide KCL as an additive to the currently running IV fluid.
  • Provider A then entered a new order for infusion of 100 mEq of KCL in 1 liter of D5W solution at a rate of 75ml/hr.
  • The order for 40 mEq of KCL through IV was supposed to be discontinued at this point but Provider A mistakenly discontinued a similar order entered by another clinician from two days earlier.
  • Provider A then received notification from the pharmacy department that the dose of 100 mEq of KCL in 1 liter of D5W was higher than the maximum allowed for the facility.
  • Provider A discontinued the order for 100 mEq of KCL in 1 liter of D5W and wrote a new order for 80mq/L KClr.
  • This new order for 80mq/L KClr was supposed to deliver 1L of fluid however the order did not specify stop time or maximum volume of fluid to be delivered.
  • As a result, the fluid continued to be administered for 36 hours. Unfortunately, Provider A unintentionally caused the patient to receive a total of 256 mEq KCL over 36 hours.
  • On Sunday morning, there was a change in coverage. Provider A asked Provider B to check the patient’s KCl level.
  • Provider B reviewed the patient’s most recent serum KCl which was taken on Saturday morning (before the infusion of potassium). The value was 3.1 mEq/ L which indicated that the patient was hypokalemic. Provider B did not realize that the lab result was indicative of the patient’s potassium status prior to unnecessary KCl repletion.
  • Provider B then ordered 60mEq KCl by injection to be given even while the previous potassium drip was still running.
  • Order entry logs revealed that another dose of 40mEq KCl IV injection was also ordered by Provider B but no clear evidence from sources indicate that it was actually given.
  • Therefore, the patient received a total volume of 316 mEq KCl over 42 hours.
  • On Monday, when the patient’s potassium levels were checked, the patient was found to be dangerously hypokalemic with a serum potassium level of 7.8 mEq/L.
  • Once the errors were discovered, immediate measures were taken and the patient was treated.


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