AMDIS: Anticipating consequences can smooth CPOE implementation
Pittsburgh Children's Hospital has fully implemented a closed loop medication administration system with bedside bar-coding, and have seen declines in administration errors, said Levin. "Mot of our remaining errors are pump programming errors—we still have work to do with the pump vendors for pediatric administration, to get those errors down,” Levin said.
Delays in charting—from time a medication was given to when it was charted—were often an hour or more before bedside barcoding, was implemented, said Levin. Prior to the implementation, charting simetimes happened at the end of the shift or when the nurse had time, and so on average it was an hour after the dose was given before it was charted. “As we started to roll out in almost all of our units, we started to see a nice decline in time from administration to charting,” and it has been a housewide decline, he said.
“We looked for similar outcomes when we implemented,” Longhurst said. “We looked to the literature to help guide our evidence-based dashboard for our entire C-suite as well as our board of directors at the hospital.” The facility conducted time and motion studies as part of the go-live and turnaround time improvements—from time of ordering to administration of stat medications and stat lab results to availability of radiographic files, he said. “We saw across-the board improvements. These are clinically tangible.”
However, “not everything is a positive outcome. Around time of our go-live, we had a bump in line infections in the NICU. Looking retrospectively, many of us feel now that there was so much emphasis placed on training … and go-live and activating support, that less emphasis was placed on than usual on hand hygiene and deep line infection.”
“Every hospital that goes live with CPOE has unintended consequences,” said Longhurst. One key to successful CPOE implementation is understanding those unanticipated consequences, both good and bad, and learning to anticipate them.
Facilities should anticipate workflow issues, said Levin. It’s important for any facility to avoid alert fatigue and make sure alerts built into the system are relevant to the patient base.
It’s also important to have an open mind when dealing with staff that have strong negative emotions—another unintended consequence of CPOE implementation. “My advice is to keep an open ear to folks with strong emotions,” Longhurst said.
Strong emotions can result from new errors: “It’s incredibly important to point out: There is no doubt that these clinical systems can introduce new types of errors,” such as errors in the process of entering information and in the communication and coordination process.
Longhurst advised the audience to “train around system limitations. You have to recognize many of these unintended consequences are result of poor system design, user interface and human-computer interaction. We as a group need to push vendors to do a better job,” he said.
“CPOE is a tool for quality improvement, but … unintended consequences are part of every implementation, and predicting these consequences is going to help you to manage them. Strategies to prevent/mitigate these types of things include utilizing highly trained clinical IT staff, including nursing informaticists [and] pharmacy informaticists … do not rely solely on your vendor,” he said. In addition, “there are a lot of lessons to be learned from over 40 years in peer-received, scientific literature, and lots of lessons to be learned from your colleagues.”