Download PICO Question and Rationale

PICO Question and Rationale
Our PICO question states: “Does the computerized physician order entry (CPOE) system
reduce the number of medication errors in pediatrics compared to the common paper system
being used today?” This question is important because the pediatric population is a high-risk
group for medication errors because the potential adverse drug event is three times greater than
an adult hospitalized patient (Levine et al., 2001). Nurses are the last defense level of protection
against medication errors, and are solely responsible for the dispensing, administering, and
monitoring of medications. In healthcare, computers can be used to help facilitate clear and
accurate communication between health care professionals. When using a computerized
physician ordering entry system it allows physicians to type in prescriptions directly into the
computer which greatly reduces any errors that can occur when deciphering handwriting. This
will help reduce the chance of an error at the very first stage in which an error could occur. It is
still the nurse’s responsibility to check the order for any errors that may have occurred in the
dispensing stages or any dosage errors done when the physician was prescribing the medication.
Safety of the patient is the primary goal of all health care professionals and preventing
medication errors at the first step in the process will help put a stop to unnecessary adverse
effects caused by medication. Thus, the CPOE will in effect decrease the number of medication
errors through ensuring legibility and completeness of orders.
Reviewing the Evidence
The evidence used to review the effect of computerized systems in the prevention of
medication errors includes research studies as well as systematic reviews. Primary research
studies include Computerized Physician Order Entry and Medication Errors in a Pediatric
Critical Care Unit, Prioritizing Strategies for Preventing Medication Errors and Adverse Drug
Events in Pediatric Inpatients, Effect of Computer Order Entry on Prevention of Serious
Medication Errors in Hospitalized Children, and The Effect of Computerized Physician Order
Entry on Medication Errors and Adverse Drug Events in Pediatric Inpatients. Systematic
reviews were also used in the review of evidence including Guidelines for preventing medication
errors in pediatrics and How Can Information Technology Improve Patient Safety and Reduce
Medication Errors in Children’s Health Care? Several search strategies were used to find
evidence including EBSCOhost, CINAHL, Health: Nursing/Academic Edition, and Google
Scholar. Databases such as Cochrane, Joanna Briggs, and AHRQ were searched; however, no
articles were used from these searches in the review. Words searched in each database include
medication errors, prevention, pediatric, computerized physician order entry system, and nursing.
Synthesis of Evidence
In the study, The Effect of Computerized Physician Order Entry on Medication Errors
and Adverse Drug Events in Pediatric Inpatients, the researchers implemented the new system of
Computerized Physician Order Entry (CPOE) on two medical wards and then compared them
with one medical and two surgical wards that continued to use hand written orders. The
researchers gathered a baseline dataset of medication errors for three years before the new CPOE
system was implemented. Then, after the CPOE system had been in practice for three years,
another set of data was collected and compared to the first baseline set. The researchers defined a
medication error as “any event involving medication prescription, dispensing, administration, or
monitoring of medications irrespective of outcome (King et al., 2003).” Also, an adverse drug
event (ADE) was defined as “a medication error resulting in an injury to the patient (King et al.,
2003).” To ensure quality and consistency within this study, the total number of patient days and
discharges during the allotted period was obtained from the CHEO discharge database “which
has a minimum dataset with definitions for each data element” (King et al., 2003). The
researchers computed the ratios of rates before and after the CPOE system was implemented per
every 1000 patient days for medication errors, potential ADEs and ADEs. In addition, in order to
evaluate the impact of introducing this system, the researchers computed the ratio of the rate
ratio for the intervention wards and the rate ratio for the control wards (King et al., 2003). The
results showed an overall MER of 4.49/1000 patient days, however the MERs before the
introduction of the system were indistinguishable. It was found that ultimately there was a 40%
reduction in the medication errors when compared to the control wards after the 3 years (King et
al., 2003). While they were able to find a decrease in the rate of medication errors, there was not
a correlating decrease on actual or potential patient injury. This study’s findings tell us that if the
CPOE system was implemented, then “it would prevent 82 medication errors per year (King et
al.).”
Another article, How Can Information Technology Improve Patient Safety and Reduce
Medication Errors in Children’s Health Care?, explains the importance of information
technology in preventing pediatric medication errors. Pediatric medicine poses a greater risk for
medication errors because it typically requires weight-based dosing, unlike most adult medicines
(Kaushal, Barker, & Bates, 2001). Pediatric patients are also at a greater risk because children
are usually not able to distinguish incorrect medication due to less developed communication
abilities (Kaushal et al., 2001). Because a child’s weight and lab values change frequently,
computerized physician order entry systems are an important aspect of preventing pediatric
medication errors because they allow the data to be updated easily (Kaushal et al., 2001).
Examples of other information technology that helps prevent medication errors include
computerized medication administration records, robots, and bar coding (Kaushal et al., 2001).
Reducing medication errors through the use of information technology leads to information
organization, connecting pieces of information, and repeating tasks (Kaushal et al., 2001). The
different tools of information technology, including the computerized physician entry order, are
able to reduce medication errors; these findings are congruent with the previous article and
support the hypothesis that computer systems are beneficial in medical settings.
Similarly, in Prioritizing Strategies for Preventing Medication Errors and Adverse Drug
Events in Pediatric Inpatients, a prospective cohort study measured the number of medication
errors made in 1020 patients in two large, tertiary care academic medical hospitals. Medication
order sheets, medical administration records, and chart reviews were gathered on every patient,
and 616 errors were found of the 10,778 medications ordered. The study was produced “to
categorize the major types of medication errors and to identify the most effective intervention
strategies for reducing medication error rates.” The findings of the study identified 77.8% of the
medication errors as direct effects of the ordering stage. A computerized physician order entry
(CPOE) system was found to be the most effective potential strategy for preventing up to 72.7%
of all medication errors: the CPOE limits problems with legibility and offers complete orders that
can often be missed with handwritten medication orders. While the statistics provide a high
correlation between the implementation of CPOE systems with decreased medication errors, the
CPOE does not affect the rate of medication errors in the administration stage. This study only
measured the potential of CPOEs for preventing errors; the CPOEs were not implemented and
then evaluated. CPOE systems come in a variety of formats with many different clinical decision
support systems, offering a wide range of potential to catch errors. A basic CPOE has the
potential to 65.9% of errors, which is a large enough percentage to recommend medical
institutions across the nation to implement CPOEs.
The authors of Computerized Physician Order Entry and Medication Errors in a
Pediatric Critical Care Unit explored the effectiveness of computerized physician order entry
(CPOE) systems on medication errors. The study’s stated purpose was “to determine the impact
of CPOE on the frequency of medication errors at the point of physician ordering in a pediatric
critical care unit (PCCU)” (Potts, A.L., Barr, F. E., Gregory, D. F., Wright, L., & Patel, N. R.,
2004). The study was set in the PCCU of an academic institution and included medication errors
from the two month period before the implementation of CPOE – October 4, 2001 to December
4 2001 – and a two month period after CPOE – January 4, 2002 to March 4, 2002 – with a one
month period in between when no data was collected in order to acclimate hospital staff (Potts et
al., 2004). Each error was categorized into one of three groups: potential adverse drug effects
(ADEs), medication prescribing errors (MPEs), and rule violations (RVs). The results showed a
95.9% reduction in total errors with a 40.9% reduction in ADEs, 99.4% in MPEs, and 97.9% in
RVs; these statistics are evident of a very significant decrease in the number of medication errors
with the use of a CPOE system, which coincides with the findings in each previously mentioned
source (Potts et al., 2004).
Yet another article, Guidelines for Preventing Medication Errors in Pediatrics, provides
guidelines for preventing medication errors in pediatric hospitalized patients; it reccommends
using organizational systems, educational systems, and manufacturing and regulatory systems to
help stop the occurrence of medication errors. A computerized physician order entry (CPOE)
system can provide many enhancements to preventing medication errors. Using the CPOE will
allow all healthcare providers to have an easily accessible list of all current medications the
patient is on and will reduce the process of ordering a medication for a patient, which will
decrease the chance of an error occuring throughout the process. This system will also allow
pharmacists, nurses, and physicians a form of communication by electronic means. In summary,
the combined effort of healthcare professionals and electronic support can greatly reduce
medication errors.
A final study found that medication errors affect 1 in 10 pediatric patients annually and
are often the easiest errors to make due to specific weight and size calculations (Walsh et al.,
2008). There are many systems being implemented in medical settings worldwide to help reduce
these problems. The most prevalent of these systems is the Computerized Physician Order Entry
(CPOE). In The Effects of Computer Order Entry on Prevention of Serious Medication Errors in
Hospitalized Children, researchers studied how the implementation of this system changed the
rate of medication errors in pediatric patients in the Boston Medical Center PICU, NICU, and on
regular surgical and medical pediatric wards (Walsh et al., 2008). This time-series analysis
included 627 pediatric patients (Walsh et al., 2008). The researchers used references such as
12672 medication orders written over 3234 patient-days in order to decipher the amount of
medication errors made, and with this data 156 errors were found (Walsh et al., 2008). Of these
156 errors, 70 were serious medication errors (Walsh et al., 2008). In general there was a 40%
reduction in reported medication errors and a 41% reduction in potentially dangerous errors after
the implantation of the CPOE; however, throughout the entire study this system only accounted
for an overall 7% decline in serious medication errors (Walsh et al., 2008). Overall, the CPOE
system is significantly reducing medication errors in pediatric units, which also supports – and is
supported by – each previously noted article.
Consistency of Evidence
A. There are not replications of studies performed. Each study was performed to explore the
outcome of medication errors and how to prevent them through various means. The different
studies had similar outcomes in the reduction of medication errors when CPOEs were
implemented although the statistics varied. Computerized physician ordering systems were a
consistent solution to reduce the frequency of medication errors.
B. Most of the studies and reviews had strong designs; however, they each had limitations. In
the studies, the strengths include the clearly outlined implementation of CPOEs such as the
instruments used, the population statistics, the trial period, and the approved review boards.
The studies offered enough information for a replication to be possible. Limitations of the
studies include populations that were not randomized or controlled, populations that were not
limited to only pediatric patients, and lack of implementation because only the potential for
medication error prevention was measured.
C. The recommendations of the systematic reviews and individual studies are consistent in the
main recommendation that CPOEs should be implemented in health-care settings. Although
the statistics from each study varied, they all showed an improvement in reducing medication
errors when CPOEs were installed. Other recommendations such as training physicians,
pharmacists, and nurses to use CPOEs and including decision support software specific to the
pediatric population were also consistent within the studies and reviews but were not
included in every article.
D. When the recommendations are applied, the patient benefits in such ways as ensuring safe
medication administration through proper doses and drug identification with the use of the
CPOE. There were no identified risks of applying the CPOE, but with any new technology
there is a risk of error when proper usage is not understood. Computers are not a perfect
technology; therefore, further evaluation of the systems will need to be continued.
E. There are no identified cost studies in the research articles but it is recognized that the
implementation of computerized systems is costly. Although specific monetary amounts are
not defined, the benefits of using the CPOE will ultimately balance the annual billion-dollar
cost of reconciling medication errors.
Recommendations
1. Hospitals and care setting implement CPOE systems.
 Grade A

Fortescue, E. B., Kaushal, R., Landrigan, C. P., McKenna, K. J., Clapp, M. D. ,...
Bates, D. W. (2003). Prioritizing strategies for preventing medication errors and adverse
drug events in pediatric inpatients. Pediatrics, 111(4), 722-729.
doi:10.1542/peds.111.4.722

Kaushal, R., Barker, K. N., & Bates, D. W. (2001). How can information technology
improve patient safety and reduce medication errors in children's health care?
Archives of Pediatrics & Adolescent Medicine, 155(9), 1002-1007. Retrieved from
http://www.archpediatrics.com

King, W. J., Paice, N., Rangrej, J., Forestell, G. J., & Swartz, R. (2003). The effect of
computerized physician order entry on medication errors and adverse drug events in
pediatric inpatients. Pediatrics, 112(3), 506-509. doi: 10.1542/peds.112.3.506

Levine, S. R., Cohen, M. R., Blanchard, N.R., Frederico, F., Magelli, M. ,… Lesko, A.
(2001). Guidelines for preventing medication errors in pediatrics. Journal of
Pediatric Pharmacology and Therapeutics, 6, 426-442. Retrieved from
http://www.jppt.org/

Potts, A.L., Barr, F. E., Gregory, D. F., Wright, L., & Patel, N. R. (2004). Computerized
physician order entry and medication errors in a pediatric critical care unit. Pediatrics,
113(1), 59-63. doi: 10.1542/peds.113.1.59

Walsh, K, Landrigan, C, Adams, W, Robert, V, Chessare, J. ,… Bauchner, H. (2008). Effect
of computer order entry on prevention of serious medication errors in hospitalized
children. Pediatrics, 121(3), Retrieved from www.pediatrics.org doi:10.1542/peds20070220
2. Doctors, pharmacists, and nurses need training on how to use CPOE systems to decrease the
chance of errors when using the system.
 Grade A

Fortescue, E. B., Kaushal, R., Landrigan, C. P., McKenna, K. J., Clapp, M. D. ,... Bates, D.
W. (2003). Prioritizing strategies for preventing medication errors and adverse drug
events in pediatric inpatients. Pediatrics, 111(4), 722-729. doi:10.1542/peds.111.4.722

Levine, S. R., Cohen, M. R., Blanchard, N.R., Frederico, F., Magelli, M. ,… Lesko, A.
(2001). Guidelines for preventing medication errors in pediatrics. Journal of Pediatric
Pharmacology and Therapeutics, 6, 426-442. Retrieved from http://www.jppt.org/

Potts, A.L., Barr, F. E., Gregory, D. F., Wright, L., & Patel, N. R. (2004).Computerized
physician order entry and medication errors in a pediatric critical care unit. Pediatrics,
113(1), 59-63. doi: 10.1542/peds.113.1.59

Walsh, K, Landrigan, C, Adams, W, Robert, V, Chessare, J. ,… Bauchner, H. (2008). Effect
of computer order entry on prevention of serious medication errors in hospitalized
children. Pediatrics, 121(3), Retrieved from www.pediatrics.org doi:10.1542/peds20070220
3. Decision support software should be added to the CPOE system for the pediatric population
including weight-based calculations.
 Grade A

Fortescue, E. B., Kaushal, R., Landrigan, C. P., McKenna, K. J., Clapp, M. D. ,... Bates, D.
W. (2003). Prioritizing strategies for preventing medication errors and adverse drug
events in pediatric inpatients. Pediatrics, 111(4), 722-729.doi:10.1542/peds.111.4.722

Kaushal, R., Barker, K. N., & Bates, D. W. (2001). How can information technology
improve patient safety and reduce medication errors in children's health care?
Archives of Pediatrics & Adolescent Medicine, 155(9), 1002-1007. Retrieved
from http://www.archpediatrics.com

Levine, S. R., Cohen, M. R., Blanchard, N.R., Frederico, F., Magelli, M. ,… Lesko, A.
(2001). Guidelines for preventing medication errors in pediatrics. Journal of Pediatric
Pharmacology and Therapeutics, 6, 426-442. Retrieved from http://www.jppt.org/

Potts, A.L., Barr, F. E., Gregory, D. F., Wright, L., & Patel, N. R. (2004). Computerized
physician order entry and medication errors in a pediatric critical care unit. Pediatrics,
113(1), 59-63. doi: 10.1542/peds.113.1.59

Walsh, K, Landrigan, C, Adams, W, Robert, V, Chessare, J. ,… Bauchner, H. (2008).
Effect of computer order entry on prevention of serious medication errors in hospitalized
children. Pediatrics, 121(3), Retrieved from www.pediatrics.org doi:10.1542/peds20070220
References
Fortescue, E. B., Kaushal, R., Landrigan, C. P., McKenna, K. J., Clapp, M. D. ,... Bates, D. W.
(2003). Prioritizing strategies for preventing medication errors and adverse drug events
in pediatric inpatients. Pediatrics, 111(4), 722-729.doi:10.1542/peds.111.4.722
Kaushal, R., Barker, K. N., & Bates, D. W. (2001). How can information technology improve
patient safety and reduce medication errors in children's health care? Archives of
Pediatrics & Adolescent Medicine, 155(9), 1002-1007. Retrieved from
http://www.archpediatrics.com
King, W. J., Paice, N., Rangrej, J., Forestell, G. J., & Swartz, R. (2003). The effect of
computerized physician order entry on medication errors and adverse drug events in
pediatric inpatients. Pediatrics, 112(3), 506-509. doi: 10.1542/peds.112.3.506
Levine, S. R., Cohen, M. R., Blanchard, N.R., Frederico, F., Magelli, M. ,… Lesko, A. (2001).
Guidelines for preventing medication errors in pediatrics. Journal of Pediatric
Pharmacology and Therapeutics, 6, 426-442. Retrieved from http://www.jppt.org/
Potts, A.L., Barr, F. E., Gregory, D. F., Wright, L., & Patel, N. R. (2004). Computerized
physician order entry and medication errors in a pediatric critical care unit. Pediatrics,
113(1), 59-63. doi: 10.1542/peds.113.1.59
Walsh, K, Landrigan, C, Adams, W, Robert, V, Chessare, J. ,… Bauchner, H. (2008). Effect of
computer order entry on prevention of serious medication errors in hospitalized children.
Pediatrics, 121(3), Retrieved from www.pediatrics.org doi:10.1542/peds2007-0220