Influence of a Novel Clinical Decision Support System on Duplicated Medication at Medical Center
Date Issued
2010
Date
2010
Author(s)
Chiu, Chien-Tzu
Abstract
Backgrounds:
Prescribing errors are the most common type of medication error and are often preventable. Integrate clinical decision support systems (CDSSs) into the computerized physician order entry (CPOE) may reduce medication error rates. Different CDSSs have been developed and integrated into CPOE successively in National Taiwan University Hospital since a new CPOE was implemented in 2007.
Objective:
The first part of the study is to integrate a novel clinical decision support system into a computerized physician order entry. The second part of the study is to know the effect of a clinical decision support system which checks therapeutic duplication and repeated prescription in inpatient department. The third part of the study, we use the medication error report system of National Taiwan University Hospital to evaluate the influence of CDSS on prescribing errors.
Method:
The first step is to integrate a novel clinical decision support system into a computerized physician order entry, which checks therapeutic duplication (the category which was developed by pharmacists in National Taiwan University Hospital) and repeated prescription, the CDSS will show a pop-out window to alert physicians when it detect there are therapeutic duplicated or repeated prescription. If the physicians decided to override the alert, he/she needs to provide a reason, the reason will show on the dispensing list also on the pharmacy on-line verification.
To evaluate the effect of clinical decision support system, we use interception rate, acceptance rate, what’s the rate of the patients can benefit from the CDSS in the population. We also estimate how much money can be saved by the CDSS. We also evaluate the influence of prescription errors reported by the pharmacists, especially the therapeutic duplication and repeated prescription.
Result:
During the study period July-Oct in 2009, there were total 727,322 new prescriptions, 27,156 patients had prescriptions, and 25,048 alerts were generated. Exclude the data which were generated by physician’s unfamiliar to the CDSS pop-out window, total 22,654 alerts were analyzed. Our study found interception rate is 3％, which means every 100 prescriptions may have 3 duplicated medications. Acceptance rate is 79.7％. One patient can benefit from the CDSS in every 1.5 patients. The CDSS can save NT＄32,759,661 in the study period, which equals to NT＄266,338 per day, NT＄97,213,370 per year. Divided by 27,156 patients who had prescriptions, which means it could save NT＄1206.4 per patient.
The acceptance rate which the CDSS detected as repeated prescription is a little higher than the CDSS detected as therapeutic duplication (82.4％ vs. 74.9％).
From the prescriptions physicians override from the CDSS, we found most of the alerts were generated because of physicians’ unfamiliar to use「specific dose order」to prescribe same drug used in different dose and different repeat pattern. The other reason
the alerts were generated because of physicians’ unfamiliar to use「refill」to order drugs which has multiple doses per package. The final reason is that physicians don’t know they can discontinue the drug directly on the pop-out alert window.
Physicians often override some of the therapeutic category, especially, physicians use different drugs both contain vitamin B, or use tow kind of α-receptor antagonist to treat BPH and hypertension in the same time, use Smecta and Pecolin suspension to treat diarrhea in the same time, use Tinten and Depain X as pain control in the same time. These kind of medication errors still need pharmacists to intervene.
The acceptance rate in some of the therapeutic categories were below average, like anti-depressant(64.7％), anti-psychotics(64.3％), drugs used in parkinsonism(70.8％), anti-vertigo(62.7％). Also the acceptance rate of psychotic department was below average(49.6％). We need to discuss with the physicians to find a solution to make our CDSS be more relevant to clinical.
Compare the prescribing errors in different period, total prescribing error rate was 0.84％ in Jul-Oct,2008, 1.6％ in Jul-Oct,2009. Physicians’ acceptance rate decreased from 91.6％ to 88.5％. The largest increase prescribing error rate was found in emergency medicine department (0.9％ to 8.9％), followed by medicine department (0.9％ to 1.7％), surgery department (1.1％ to 2.2％) and pediatric department (1.2％ to 2.2％). Of all the inpatient pharmacies, the largest increase prescribing error rate was found in inpatient pharmacy in main region, which was 921 prescribing errors /month, increase to 2461 prescribing errors /month.
The reason “pharmacist advice to monitor”, increased 5-fold. The reason ” pharmacist advice to change the order” also increased 2-fold, some of the prescribing errors reported by the pharmacist has the tag in the page for pharmacists’ on-line verification, like the subgroup “dose/frequency”, “infusion rate”, “combination problem”, ”drug-drug interaction”, these prescribing errors also increased. The other prescribing errors with no tag in the page of pharmacists’ online verification also increase, like “medication route and formulation problem”, “drug contraindication”, “drug compatibility”, “advise to use better drug” and “pharmacist advice to monitor”.
In the total new prescriptions, the percentage of prescribing errors reported as “therapeutic duplication which can be detected by CDSS” decreased a little (0.06％ decrease to 0.04％), acceptance rate also decreased (82.8％ to 72％). In the total new prescriptions, the percentage of prescribing errors reported as “repeated prescriptions which can be detected by CDSS” increased 10-fold (0.01％ increase to 0.1％),
acceptance rate decreased a little (96.8％ to 92.4％).
Conclusion:
The effect of CDSS implemented in National Taiwan University Hospital is good, our study found interception rate 3％, acceptance rate 79.7％, One patient can benefit from the CDSS in every 1.5 patients. We need to guide new physicians to use「specific dose order」、「refill」 to prescribe some type of medication, and also promote physicians to value the CDSS.
Subjects
Clinical decision support system
computerized physician order entry
prescribing error
medication error
duplicated medication
therapeutic duplication
repeated prescription
SDGs
Type
thesis
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