Using a computerized provider order entry system to meet the unique prescribing needs of children: description of an advanced dosing model

BackgroundIt is well known that the information requirements necessary to safely treat children with therapeutic medications cannot be met with the same approaches used in adults. Over a 1-year period, Duke University Hospital engaged in the challenging task of enhancing an established computerized provider order entry (CPOE) system to address the unique medication dosing needs of pediatric patients.MethodsAn advanced dosing model (ADM) was designed to interact with our existing CPOE application to provide decision support enabling complex pediatric dose calculations based on chronological age, gestational age, weight, care area in the hospital, indication, and level of renal impairment. Given that weight is a critical component of medication dosing that may change over time, alerting logic was added to guard against erroneous entry or outdated weight information.ResultsPediatric CPOE was deployed in a staggered fashion across 6 care areas over a 14-month period. Safeguards to prevent miskeyed values became important in allowing providers the flexibility to override the ADM logic if desired. Methods to guard against over- and under-dosing were added. The modular nature of our model allows us to easily add new dosing scenarios for specialized populations as the pediatric population and formulary change over time.ConclusionsThe medical needs of pediatric patients vary greatly from those of adults, and the information systems that support those needs require tailored approaches to design and implementation. When a single CPOE system is used for both adults and pediatrics, safeguards such as redirection and suppression must be used to protect children from inappropriate adult medication dosing content. Unlike other pediatric dosing systems, our model provides active dosing assistance and dosing process management, not just static dosing advice.

[1]  J. Robertson,et al.  The Harriet lane handbook: A manual for pediatric House officers , 2005 .

[2]  Y. Han,et al.  Han YY, Carcillo JA, Venkataraman ST, Clark RS, Watson RS, Nguyen TC, Bayir H, Orr RA. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics , 2011 .

[3]  V. Gunn,et al.  The Harriet Lane handbook : a manual for pediatric house officers , 1996 .

[4]  Brian Jacobs.  Hardly child's play: implementing a pediatric-specific, integrated CPOE system. Midwest pediatric hospital tackles all the hurdles--needs assessment, clinician buy-in, training and measuring results--as it strengthens its patient safety efforts with wireless CPOE. , 2004, Health management technology.

[5]  Rainu Kaushal,et al.  Time to tackle the tough issues in patient safety. , 2002, Pediatrics.

[6]  Kaveh G Shojania,et al.  The frustrating case of incident-reporting systems , 2008, Quality & Safety in Health Care.

[7]  A. Potts,et al.  Computerized physician order entry and medication errors in a pediatric critical care unit. , 2004, Pediatrics.

[8]  Y. Han,et al.  Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry System , 2005, Pediatrics.

[9]  A. Egberts,et al.  The Effect of Computerized Physician Order Entry on Medication Prescription Errors and Clinical Outcome in Pediatric and Intensive Care: A Systematic Review , 2009, Pediatrics.

[10]  Carol Taketomo,et al.  Pediatric Dosage Handbook: Including Neonatal Dosing, Drug Administration, & Extemporaneous Preparations , 2009 .

[11]  J. Benes,et al.  The impact of hospitalwide computerized physician order entry on medical errors in a pediatric hospital. , 2005, Journal of pediatric surgery.

[12]  M. Modan,et al.  Errors in computing drug doses. , 1983, Canadian Medical Association journal.

[13]  B. Anderson,et al.  Common errors of drug administration in infants: causes and avoidance. , 1999, Paediatric drugs.

[14]  Julie M. Whitehurst,et al.  A Multifaceted Approach to Safety: The Synergistic Detection of Adverse Drug Events in Adult Inpatients , 2008 .

[15]  D. Bates,et al.  Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. , 1998, JAMA.

[16]  Rainu Kaushal,et al.  To What Extent Do Pediatricians Accept Computer-Based Dosing Suggestions? , 2007, Pediatrics.

[17]  E. Stucky,et al.  Prevention of medication errors in the pediatric inpatient setting. , 2003, Pediatrics.

[18]  H. Bauchner,et al.  Effect of Computer Order Entry on Prevention of Serious Medication Errors in Hospitalized Children , 2008, Pediatrics.

[19]  Monica M. Horvath,et al.  Reevaluating the Safety Profile of Pediatrics: A Comparison of Computerized Adverse Drug Event Surveillance and Voluntary Reporting in the Pediatric Environment , 2008, Pediatrics.

[20]  Matthew A. Eisenberg,et al.  Computerized Provider Order Entry Implementation: No Association With Increased Mortality Rates in an Intensive Care Unit , 2006, Pediatrics.

[21]  D. Bates,et al.  How can information technology improve patient safety and reduce medication errors in children's health care? , 2001, Archives of pediatrics & adolescent medicine.

[22]  D. Bates,et al.  Medication errors and adverse drug events in pediatric inpatients. , 2001, JAMA.

[23]  G. J. Kuperman,et al.  Bates DW, Leape LL, Cullen DJ, Laird N, Petersen LA, Teich JM, Burdick E, HicSheakey M, Kleefield SB, Vander Vliet M, Seger DL, Effect of computerized physician order entry and a team intervention on prevention of serious medication errors , 1999, Journal of Clinical Monitoring and Computing.

[24]  Gilad J. Kuperman,et al.  Editorial Comments: Using Commercial Knowledge Bases for Clinical Decision Support: Opportunities, Hurdles, and Recommendations , 2006, J. Am. Medical Informatics Assoc..

[25]  Phillip W. Stewart,et al.  Enhancing Computerized Provider Order Entry (CPOE) for Neonatal Intensive Care , 2003, AMIA.

[26]  J. Sullivan,et al.  Medication errors in pediatrics—the octopus evading defeat , 2004, Journal of surgical oncology.

[27]  C. Longhurst,et al.  Decrease in Hospital-wide Mortality Rate After Implementation of a Commercially Sold Computerized Physician Order Entry System , 2010, Pediatrics.

[28]  D. Bates,et al.  Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients. , 2003, Pediatrics.

[29]  G. Kadmon,et al.  Computerized Order Entry With Limited Decision Support to Prevent Prescription Errors in a PICU , 2009, Pediatrics.

[30]  Megan M. Tschudy,et al.  The Harriet Lane handbook : a manual for pediatric house officers , 2012 .

[31]  B. Anderson,et al.  Common Errors of Drug Administration in Infants , 1999 .

[32]  J C Russo,et al.  Medication error prevention by clinical pharmacists in two children's hospitals. , 1987, Pediatrics.