David Gregory, director of Vanderbilt Children's Hospital pharmacy services, uses the computerized drug ordering system in the VCH pharmacy. Photo by Dana Johnson
Study shows electronic prescriptions safer for kids
It’s a nightmarish scenario. A doctor writes a prescription for dopamine at 5 micrograms. But the pharmacy reads her handwriting incorrectly and dobutamine is sent to the patient. Or maybe the doctor meant to write dobutamine, but in a big hurry after a 40 hour shift leaves important information about the mix of the medication off the slip.
Research shows medication errors are probably as common in pediatrics as they are in adult medicine. The fear is they might be as deadly as well. A report by the Institute of Medicine found between 44,000 and 98,000 people die each year in the United States partly as a result of medical errors. It is not known how many of those who die are children.
Researchers at Vanderbilt Children’s Hospital have tested a new computerized system for writing prescriptions that could nearly eliminate some types of errors, and likely would save some children from injury or even death. The results of their research are published in January’s issue of Pediatrics.
The authors of the study Dr. Neal Patel, a pediatric critical care doctor at Vanderbilt Children’s Hospital, pharmacist David F. Gregory, director of the Vanderbilt Children’s Hospital pharmacy, Dr. Frederick Barr, critical care physician, and Vanderbilt Children’s pharmacists Lori Wright and Amy Potts, took advantage of the perfect opportunity to see how a “paperless” prescribing system at Vanderbilt Children’s might prevent medication errors.
“We were going to a computerized drug order entry system at the Critical Care Unit at Vanderbilt Children’s anyway, so we took advantage of that transition to do a prospective study, that is look at the current paper prescription writing system, then compare it to the paperless system once we changed over,” Patel said.
Starting in October of 2001, Patel and Barr reviewed the hand written medication orders on the charts of 514 patients in the Pediatric Critical Care Unit (PCCU) at Vanderbilt Children’s. They searched for various types of errors in writing the prescriptions. They found plenty. Of the 6,803 hand-written orders examined, almost 40 percent were found to have errors.
The most common type of error, called a medication prescribing error was virtually eliminated. These errors happen in either the actually writing of the paper prescription, or in the reading of it at the pharmacy. They are related legibility and abbreviation and incomplete information as the doctor hand-writes the order.
A computerized system for ordering medications called WizOrder was then put into place in the PCCU, specially modified for children. Then starting in January of 2002, a similar sized sample of charts was reviewed and was examined for errors for a post-computerization comparison.
All told, 13,828 medication orders were examined by pharmacy staff.
Medication prescribing errors dropped 95 percent after computers were implemented. Less frequent, but more serious problems called rule violations (RVs) were nearly eliminated. The rarest type of problem, called adverse drug event error, having to do with a physician making the wrong choice of drug, or selecting an improper amount, or other errors, was reduced by about 40 percent.
“This was so important because Vanderbilt Children’s is among a very small number of children’s hospitals now using computerized medication entry, and there hasn’t been any research to document what these systems actually do for patients,” said David Gregory. “The systems are very expensive, they can cost between $1 million to $10 million dollars to implement, depending on how advanced your information systems are.”
National health care advisory groups are pushing hospitals to use the computerized systems to prevent thousands of deaths and injuries, but pediatric hospitals are lagging far behind the adult hospitals in putting them in.
Part of the reason is that prescribing pediatric medicine is far more complex than it is for adults because there is such variety from patient to patient in the size and age of the child, and even how much or little their system can take.
The researchers said computerized prescription writing has been a hard sell for doctors at some institutions, who worry that doing away with hand written prescriptions might open up the possibility that a doctor might slip into the habit of allowing the computer to do the work.
Gregory said he doesn’t believe that concern is founded.
“People say, well that’s kind of like practicing cookbook medicine, it’s a great double check, because the physicians are running through the calculations in their heads and when it pops up on the screen it’s a nice confirmation of what they’re thinking,” said Gregory.
But this study is just the beginning. Patel says the next step is to see how computers and other systems can be improved to prevent adverse drug effects.
“The WizOrder system does a pretty good job of alerting you to an extreme error but there are important subtleties in children that aren’t there for adults. So what we need is a smart system,” says Patel. “One that has clinical decision support, so when you enter figures, it offers advice or further prompts to make a better decision.”
Gregory says continued advancements in computer prescribing systems could further improve outcomes.
“Just recently another institution had an unfortunate mistake that contributed to a child’s death. Obviously, one death from a medication error is one too many.”