Computerized reminders to monitor liver function to improve the use of etretinate
Introduction
Adverse drug events (ADEs) are serious and common problems. When two studies were conducted at Latter Day Saint Hospital, Salt Lake City, UT, in different periods, ADEs complicated almost 2% of all admissions [1], [2]. In the Medical Practice Study (MPS), 3.7% of patients hospitalized in New York State in 1984 suffered an ADE, which was defined as an injury due to medical treatment [3]. The leading cause of medical injury in the MPS was the use of drugs, which accounted for 19.4% of these injuries [4]. ADEs may account for up to 140 000 deaths annually in the USA [5]. In one study, a fifth of all deaths were due to adverse drug events [6]. ADEs are also an increasingly common reason for litigation [7]. Similar statistics are not available in Japan where necessary clinical databases have not been developed for research.
ADRs are not only detrimental but also very costly. The occurrence of an ADE in an inpatient setting has been associated with increased length of stay of 2 days and an increased cost of approximately US$3000 [2], [8]. Sadly, many ADEs are preventable since they are caused by medication errors [9], [10], [11], [12], [13], [14]. The most common factors associated with these medication errors are inadequate knowledge or application of knowledge regarding drug therapy and unavailability of patient information, such as the results of laboratory tests [11], [15].
There are limits to human capabilities as information processors that assure the occurrence of random errors in complex activities [18]. Moreover, excessive amounts of data may cause clinicians to overlook important alterations in clinical indexes [19]. Changing the systems by which drugs are ordered and administered holds substantial potential for reducing the number of drug-related injuries. Computerized ordering systems, in which orders are written on-line by a physician and the physician receives feedback on the suitability of the order during the process of making it, are likely to have an especially large impact on reducing medication errors [14].
Computer-based clinical information systems offer the prospect of both improving the quality of health care by reducing such errors [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38] and lowering costs [39], [40], [41], [42], [43]. Computerized reminders are among the most widely tested and promising information systems [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31]. Most studies of these approaches have been conducted in the USA; we have not seen similar reports in English from Asian settings.
One recent study showed that the computer-based electronic mail alerts about patients with rising creatinine levels reduced significantly the risk of subsequent serious renal impairment [31]. However, in that study, 28% of clinicians found the alerts annoying. Considering the fact that medication errors mainly occur in the process of prescribing, computerized alerts might prevent clinicians from prescribing drugs when an abnormality has been found in the monitored laboratory test. Furthermore, such laboratory tests are often not carried out strictly according to the intervals recommended in the Drug Package Insert. Thus, we sought to determine whether a computerized reminder during the process of prescribing could improve use of one drug according to the recommendation of its drug package insert. Data about both prescription and cancellation of the subject drug were automatically sent by electronic mail (e-mail) to us for monitoring and analysis whenever a clinician submits prescription or cancellation.
Section snippets
Setting
The study was conducted at a 1040 bed tertiary care and teaching hospital in Tokyo. The hospital cares for approximately 2500 outpatients per day. The computerized medical information system has been operational since 1973, the physician order entry system for laboratory tests since 1987, and the ordering systems for prescribing to inpatients since 1988 and outpatients since 1994. Test results and prescription details over an 8-year period can be searched in real time. Moreover, physicians can
Change in proportion of appropriate prescribing
During the pre-intervention period, 491 prescriptions of etretinate were prescribed by 37 physicians for 54 patients. Of these, 467 prescriptions (95.1%) were for outpatients and 24 (4.9%) were for inpatients. The average age of these patients was 59.4 (S.D. 13.0) years old. There were 12 females (56.6±16.0 years old) and 42 males (60.2±12.2 years). Overall prescribing for etretinate remained approximately the same in the post-intervention period; 533 prescriptions of etretinate were prescribed
Discussion
We developed a system of computerized reminders to improve the quality of care associated with use of etretinate. The frequency of prescribing etretinate was approximately equal in the pre-intervention and post-intervention periods and no major changes occurred during this time except for the implementation of the alert system. With this system, prescription of etretinate with a normal ALT or AST result within three months increased from 25.9% in the pre-intervention period to 66.2% in the
Acknowledgements
We would like to thank the pharmacists, physicians, and other personnel on the clinical units, especially Kunimoto Tamaki and Tatsuji Iga, for their support in carrying out the study. We acknowledge Stephen B. Soumerai, Yasuo Ohashi and Chikuma Hamada, for invaluable comments on the study.
References (58)
- et al.
Application of a computerized medical decision-making process to the problem of digoxin intoxication
J. Am. Coll. Cardiol.
(1984) - et al.
Computer-assisted optimization of aminophylline therapy in the emergency department
Am. J. Emerg. Med.
(1989) - et al.
Etretinate therapy
J. Am. Acad. Dermatol.
(1987) - et al.
Retinoid hepatitis
J. Am. Acad. Dermatol.
(1993) - et al.
Computerized surveillance of adverse drug events in hospital patients
J. Am. Med. Assoc.
(1991) - et al.
Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality
J. Am. Med. Assoc.
(1997) - et al.
Incidence of adverse events and negligence in hospitalized patients: results from the Harvard Medical Practice Study I
N. Engl. J. Med.
(1991) - et al.
The nature of adverse events in hospitalized patients: results from the Harvard Medical Practice Study II
N. Engl. J. Med.
(1991) - et al.
Drug-related deaths among medical inpatients
J. Am. Med. Assoc.
(1977) - et al.
Coroner's cases of death due to errors in prescribing or giving medicines or to adverse drug reactions: Birmingham 1986–1991
J. R. Soc. Med.
(1994)
Is there a cure for drug errors?
Br. Med. J.
For the Adverse Drug Events Prevention Study Group: the costs of adverse drug events in hospitalized patients
J. Am. Med. Assoc.
Incidence and preventability of adverse drug events in hospitalized adults
J. Gen. Intern. Med.
Relationship between medication errors and adverse drug events
J. Gen. Intern. Med.
Systems analysis of adverse drug events
J. Am. Med. Assoc.
Hospitalisation for adverse events related to drug therapy: incidence, avoidability and costs
Med. J. Aust.
Drug-related hospital admissions
Pharmacotherapy
Medication errors: how common are they and what can be done to prevent them?
Drug Saf.
Factors related to errors in medication prescribing
J. Am. Med. Assoc.
Protocol-based computer reminders, quality of care and the nonperfectability of man
N. Engl. J. Med.
Use of a computer to detect and respond to clinical events: its effect on clinician behavior
Ann. Intern. Med.
Physician response to computer reminders
J. Am. Med. Assoc.
Improving the consistency with which investigations are requested
Med. Inf.
A computer-based monitoring system for follow-up of elevated blood pressure
Med. Care
Reminders to physicians from an introspective computer medical record. A two-year randomized trial
Ann. Intern. Med.
Delayed feedback of physician performance versus immediate reminders to perform preventive care. Effects on physician compliance
Med. Care
Computer predictions of abnormal test results. Effects on outpatient testing
J. Am. Med. Assoc.
Computerized reminders to encourage cervical screening in family practice
J. Fam. Pract.
Promoting cancer prevention activities by primary care physicians: results of a randomized, controlled trial
J. Am. Med. Assoc.
Cited by (13)
The Effect of Electronic Prescribing on Medication Errors and Adverse Drug Events: A Systematic Review
2008, Journal of the American Medical Informatics AssociationCitation Excerpt :Overall, we identified 172 evaluation studies and 15 systematic reviews. From the 172 evaluation studies, 27 studies met all the inclusion criteria and were, therefore, included in a detailed review.8,19–44 For details, see Figure 1, available online at www.jamia.org.
The use and interpretation of quasi-experimental studies in medical informatics
2006, Journal of the American Medical Informatics AssociationEvaluation of an automated test ordering and feedback system for general practitioners in daily practice
2004, International Journal of Medical InformaticsUsing Web technologies for implementing testing strategies
2002, Clinics in Laboratory MedicineElectronic drug prescription: Auto pilot for drug therapy?
2015, Medizinische Monatsschrift fur PharmazeutenComputerized advice on drug dosage to improve prescribing practice
2013, Cochrane Database of Systematic Reviews