© 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...
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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
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
0 E
ve
nts
Post-InterventionPre-Intervention
Time to Modification or Discontinuation
0
5
10
15
20
25
30
35
High Toxicity Moderate Toxicity
Me
dia
n H
ou
rs
© 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.
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