© VANDERBILT UNIVERSITY 2009

B I O M E D I C A L I N F O R M A T I C S

A System to Improve

Medication Safety

in the Setting of

Acute Kidney Injury

Intervention

Passive Alert

Intrusive Alert

Allison B. McCoy, MS

Josh F. Peterson, MD, MPH

Cynthia S. Gadd, PhD, MBA, MS

Lemuel R. Waitman, PhD

Department of Biomedical Informatics

Vanderbilt University Medical Center

OBJECTIVE:

To improve provider response

to acute kidney injury using a computerized

provider order entry intervention.

INTRODUCTIONInadequate dosing for nephrotoxic or renally cleared

drugs in patients with acute kidney injury (AKI) is

common, though recent clinical decision support

systems have proven successful in decreasing

errors.

INTERVENTIONA computerized provider order entry (CPOE)

intervention alerted providers about 0.5 mg/dl or

greater increases in serum creatinine, advising

discontinuation or modification of nephrotoxic or

renally cleared drugs.

A passive alert appeared as persistent text within

the CPOE system and on rounding reports,

requiring no provider response.

An intrusive alert interrupted the provider at the end

of the CPOE session, requiring the provider to

modify or discontinue the drug order, assert that the

current dose was correct, or defer the alert to

reappear in the next CPOE session.

MEASUREMENTSWe evaluated the interventions, using as our

outcomes the rate of order modification or

discontinuation within 24 hours, the time to

modification or discontinuation, and the provider

response to the alerts.

RESULTSThe rate of order modification or discontinuation

increased from 40.1 to 61 actions per 100 events (p

< 0.001) for high toxicity drugs and 38.9 to 48.4

actions per 100 events (p < 0.001) for moderate

toxicity drugs.

The median time to order modification or discontinuation

decreased from 28.3 to 10.2 hours (p < 0.001) for high

toxicity drugs and 31.1 to 20.4 hours (p < 0.001) for

moderate toxicity drugs.

After viewing only a passive alert, providers modified or

discontinued 26.9% of orders. For those not

immediately modified or discontinued, providers chose

to initially defer 78.1% of the intrusive alerts.

Providers selected “modify” or “discontinue” as the

terminal response during 12.2% and 8.1% of the

displayed intrusive alerts respectively, and “correct

dose” during 42.5%.

CONCLUSIONThe intervention improved provider response to AKI,

though frequent provider deferrals suggested future

enhancements to increase success.

ACKNOWLEDGEMENT: This work was funded by T15

LM007450-06 and R03 LM009238-02.

Results

Rate of Modification or Discontinuation within 24 Hours

0

10

20

30

40

50

60

70

High Toxicity Moderate Toxicity

Actio

ns p

er

10

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ve

nts

Post-InterventionPre-Intervention

Time to Modification or Discontinuation

0

5

10

15

20

25

30

35

High Toxicity Moderate Toxicity

Me

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n H

ou

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© VANDERBILT UNIVERSITY 2009

B I O M E D I C A L I N F O R M A T I C S

Implementation Sciences

Vanderbilt

Implementation Sciences

Laboratory

Nancy Lorenzi, PhD, MLS, MA, Director

Department of Biomedical Informatics

Vanderbilt University Medical Center

OBJECTIVE:

The Implementation Sciences Laboratory (ISL) in the

Department of Biomedical Informatics is a community

of scholars interested in achieving implementation

goals for information-based systems to support

operations, research, and education in complex

healthcare organizations.. .

CURRENT PROJECTS

Current Implementation Sciences Laboratory Projects are focused on three areas of translational research:Understanding and improving adoption of technology-enabled treatment strategiesGaining clinical acceptance of Evidence-Based Medicine by clinicians Developing strategies, processes, and methods that lead to greater adoption and acceptance for community health research.

Implementation Chasm

The Department of Biomedical Informatics has a number of full-time faculty, clinical faculty and students studying biomedical informatics and adoption of information-based systems. Research in the understanding of why people do or do not adopt new technology, processes, and other innovations is primarily qualitative and people/organization-based.

Project Concept Personnel DescriptionEvaluation of regional information access by clinicians (RHIO)

Johnson, Gadd Emergency Medicine physicians can now readily gain additional information to support patient care. In addition to the traditional evaluation, data will also be collected to determine if physicians seek information from the regional resource for care of the patient.

The impact of workflow-related issues on adoption of a new technologies

Unertl, Lorenzi, Johnson One of the constant challenges to the adoption and acceptance of new technology or methods is that they are not compatible with the workflow of the clinical area. This will be a major study to assess the impact of workflow on technology adoption and to develop new tools and methodologies for workflow studies.

The use and adoption of personal health records

Johnson, Weiss The Robert Wood Johnson Foundation created Project Health Design to see how personal health records could be effectively designed for use by patients.

New technology can help to address the medication safety issues in health care, but adoption is a problem

Novak, Lorenzi, Gadd Creating Safety Research: Research has shown benefits of medication safety technologies such as barcode medication administration and electronic prescribing. However, implementation and adoption of these systems are a major challenge. A qualitative study of the strategies that individuals and organizations use to incorporate medication safety technologies into everyday clinical practice will be implemented.

Connecting clinicians and patients for more successful long term outcome

Weiss, Lorenzi The Middle Survivorship Network: The purpose of this research is to design and evaluate an online environment for individuals and groups in the middle cancer survivorship community.

Decision Support to Improve Medication Safety in Changing Renal Function

McCoy, Waitman, Peterson, Gadd

An evaluation of a multi-level decision support intervention to improve provider response to medication safety in changing renal function.

Investigating Nurse-Managed Protocol Usage Campion,Waitman,Lorenzi, Gadd

A qualitative study of nurse management of patient care protocols and advisors embedded in care provider order entry systems.

Lorenzi NM, Novak LL, Weiss JB, Gadd CS, Unertl KM. Crossing the Implementation Chasm: A Proposal for Bold Action. Journal of the American Medical Informatics Association 15(3) May/June 2008.