Effects of an integrated clinical information system on medication safety in a multi-hospital setting

Background:

Rates of preventable adverse drug events range from 380,000 to 450,000 annually, costing roughly $3.5 billions in hospital cost, resulting in estimated 7000 deaths.

Objective:

This study was designed to evaluate the effect of a vendor-based integrated clinical information system technology on medication errors throughout the medication-use process in a multi-hospital healthcare system.

Setting:

Integrated multi-hospital health care system in Rhode Island.

Interventions:

Implemented Technology – custom integration of the following components

Computer Physician Order Entry (CPOE) – A commercial CPOE system was selected based on ready interoperability with other hospital information system.

Pharmacy information system - A custom interface between the CPOE system and the pharmacy information system was built according to the institution’s requirement. This interface allowed reliable and automatic cross over of medications orders from CPOE and pharmacy information system, thereby assuring the currency of the medication profile.

Clinical Decision Support System - Inherent functionalities of CPOE and pharmacy information system, along with newly developed interface between these components enable 1) drug allergy alerts, duplication alerts, medical dosing support, Two specific rules that were implemented: alerts to clinicians of elevated creatinine (>1.5 mg/dL) when metformin or colchicine were being prescribed. Alerts based on laboratory results and maximum dosing alerts were also possible in this integrated system.

Electronic drug dispensing system (EDDS) - These systems are directly placed on the nursing units and the operating rooms. Except for emergent drugs, a medication cannot be dispensed unless a pharmacist had reviewed and approved the medication order.

Bar-code point-of-care medication administration system (BPOC) - This component offered automatic electronic safeguards for the transcription and administration processes.

Outcomes:

Primary outcome was the reduction in related medication errors. Secondary endpoints included reduction in order turnaround time and automatic dispensing machine override transactions. Selected indicators were used to measure the effects of individual systems and the integrated systems.

Results:

Indicators Preimplementation Post-implementation p-value

Inherent CDSS functionalities (numbers of intercepted errors)

Drug allergy 833 109 <0.001

Excessive dose 1341 871 <0.001

Duplication 665 584 0.127

Incomplete or unclear order 1976 663 <0.001

Rules engine software CDSS functionalities

Colchicine dosage adjustment 44 26 0.078

Metformin dosage adjustment 101 66 <0.001

CDSS functionalities integrated with pharmacy information systems and laboratory information

Dose adjustments for renal insufficiency 466 935 <0.001

Dose adjustment for drug levels outside the therapeutic range 42 258 <0.001

EDDS

Order turnaround time 90 minutes 11 minutes

EDDS override rates 7.1% 2.9% <0.001

BPOC

Intercepted errors after implementation

Wrong patient 5.5 errors intercepted per 1000 pt-days

Wrong drug, dose, or route 2.6 errors intercepted per 1000 pt-days

Wrong time 25 errors intercepted per 1000 pt-days

Conclusions:

Integrated clinical information system technology decreased selected types of medication errors throughout the medication-use process in a single health care system. These technologies also improved therapeutic drug monitoring in-patient with renal insufficiency and in patients receiving drugs with narrow therapeutic ranges through use of CDSS alerts.