Transcript Medication Safety in Ambulatory Care Thursday, February 15, 2007 12:00 – 1:00 p.m.

Medication Safety in Ambulatory Care
Thursday, February 15, 2007
12:00 – 1:00 p.m. Eastern Time
Moderator:
Karen Frush, MD, FAAP
Chief Patient Safety Officer
Duke University Health System
Durham, North Carolina
This activity was funded through an educational
grant from the Physicians’ Foundation for Health
Systems Excellence.
Disclosure of Financial Relationships and
Resolution of Conflicts of Interest for AAP CME Activities Grid
The AAP CME program aims to develop, maintain, and increase the competency, skills, and professional
performance of pediatric healthcare professionals by providing high quality, relevant, accessible and costeffective educational experiences. The AAP CME program provides activities to meet the participants’
identified education needs and to support their lifelong learning towards a goal of improving care for
children and families (AAP CME Program Mission Statement, August 2004).
The AAP recognizes that there are a variety of financial relationships between individuals and commercial
interests that require review to identify possible conflicts of interest in a CME activity. The “AAP Policy on
Disclosure of Financial Relationships and Resolution of Conflicts of Interest for AAP CME Activities” is
designed to ensure quality, objective, balanced, and scientifically rigorous AAP CME activities by identifying
and resolving all potential conflicts of interest prior to the confirmation of service of those in a position to
influence and/or control CME content. The AAP has taken steps to resolve any potential conflicts of
interest.
All AAP CME activities will strictly adhere to the 2004 Updated Accreditation Council for Continuing Medical
Education (ACCME) Standards for Commercial Support: Standards to Ensure the Independence of CME
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commercial interest: identification of CME needs, determination of educational objectives, selection and
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The purpose of this policy is to ensure all potential conflicts of interest are identified and mechanisms to resolve
them prior to the CME activity are implemented in ways that are consistent with the public good. The AAP
is committed to providing learners with commercially unbiased CME activities.
DISCLOSURES
Activity Title:
Safer Health Care for Kids - Webinar
Medication Safety in Ambulatory Care
February 15, 2007
Activity Date:
DISCLOSURE OF FINANCIAL RELATIONSHIPS
All individuals in a position to influence and/or control the content of AAP
CME activities are required to disclose to the AAP and subsequently to
learners that the individual either has no relevant financial relationships or
any financial relationships with the manufacturer(s) of any commercial
product(s) and/or provider of commercial services discussed in CME
activities.
Name
Name of
Commercial
Interest(s)*
(*Entity
producing
health care
goods
or services)
Nature of
Relevant
Financial
Relationship(s)
(If yes, please list:
Research Grant,
Speaker’s Bureau,
Stock/Bonds
excluding mutual
funds, Consultant,
Other - identify)
CME Content Will
Include
Discussion/
Reference to
Commercial
Products/Services
Disclosure of Off-Label
(Unapproved)/Investigational Uses of Products
AAP CME faculty are required to disclose to the AAP
and to learners when they plan to discuss or
demonstrate pharmaceuticals and/or medical devices
that are not approved
Heather McPhillips,
MD, MPH, FAAP
No
No
No
No
Karen P. Zimmer,
MD, MPH, FAAP
No
No
No
No
DISCLOSURES
SAFER HEALTH CARE FOR KIDS - PROJECT ADVISORY COMMITTEE AND STAFF
DISCLOSURE OF FINANCIAL RELATIONSHIPS
All individuals in a position to influence and/or control the content of AAP CME ac tivities are required to disclose to the AAP and
subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the
manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in CME activities.
Name
Name of
Commercial
Interest(s)*
(*Entity producing
health care goods
or services)
Nature of Relevant
Financial Relationship(s)
(If yes, please list:
Research Grant, Speaker’s
Bureau, Stock/Bonds
excluding mutual funds,
Consultant, Other - identify)
CME Content Will Include
Discussion/
Reference to Commercial
Products/Services
Disclosure of Off-Label
(Unapproved)/Investigational Uses
of Products
AAP CME faculty are required to
disclose to the AAP and to learners
when they plan to discuss or
demonstrate pharmaceuticals and/or
medical devices that are not approved
Karen Frush, MD, FAAP
(PAC Member)
No
No
No
No
Uma Kotagal, MD, MBBS,
MSc, FAAP (PAC Member)
No
No
No
No
Christopher Landrigan, MD,
MPH, FAAP (PAC Member)
No
No
No
No
Marlene R. Miller, MD, MSc,
FAAP (PAC Chair)
No
No
No
No
Paul Sharek, MD, MPH.
FAAP (PAC Member)
No
No
No
No
Erin Stucky, MD, FAAP (PAC
Member)
No
No
Not sure
No
Nancy Nelson (AAP Staff)
No
No
No
No
Melissa Singleton, MEd
(Project Manager – AAP
Consultant)
No
No
No
No
Junelle Speller (AAP Staff)
No
No
No
No
Linda Walsh, MAB (AAP
Staff)
No
No
No
No
DISCLOSURES
AAP COMMITTEE ON CONTINUING MEDICAL EDUCATION (COCME)
DISCLOSURE OF FINANCIAL RELATIONSHIPS
All individuals in a position to influence and/or control the content of AAP CME ac tivities are required to disclose to the AAP and
subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the
manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in CME activities.
Name
Name of
Commercial
Interest(s)*
(*Entity producing
health care goods
or services)
Nature of Relevant
Financial Relationship(s)
(If yes, please list:
Research Grant, Speaker’s
Bureau, Stock/Bonds
excluding mutual funds,
Consultant, Other - identify)
CME Content Will Include
Discussion/
Reference to Commercial
Products/Services
Disclosure of Off-Label
(Unapproved)/Investigational Uses
of Products
AAP CME faculty are required to
disclose to the AAP and to learners
when they plan to discuss or
demonstrate pharmaceuticals and/or
medical devices that are not approved
Ellen Buerk, MD, FAAP
No
No
No
No
Meg Fisher, MD, FAAP
No
No
No
No
Robert A. Wiebe, MD, FAAP
No
No
Not sure
No
Jack Dolcourt, MD, FAAP
No
No
No
No
Thomas W. Pendergrass, MD,
FAAP
No
No
No
No
Beverly P. Wood, MD, FAAP
No
No
No
No
CME CREDIT
The American Academy of Pediatrics (AAP) is accredited by the
Accreditation Council for Continuing Medical Education to
provide continuing medical education for physicians.
The AAP designates this educational activity for a maximum of 1.0
AMA PRA Category 1 Credit™. Physicians should only claim
credit commensurate with the extent of their participation in
the activity.
This activity is acceptable for up to 1.0 AAP credit. This credit can
be applied toward the AAP CME/CPD Award available to Fellows
and Candidate Fellows of the American Academy of Pediatrics.
OTHER CREDIT
This webinar is approved by the National Association of Pediatric
Nurse Practitioners (NAPNAP) for 1.2 NAPNAP contact hours of
which 1.0 contain pharmacology (Rx) content. The AAP is
designated as Agency #17. Upon completion of the program,
each participant desiring NAPNAP contact hours should send a
completed certificate of attendance, along with the required
recording fee ($10 for NAPNAP members, $15 for
nonmembers), to the NAPNAP National Office at 20 Brace
Road, Suite 200, Cherry Hill, NJ 08034-2633.
The American Academy of Physician Assistants accepts AMA PRA
Category 1 Credit(s)TM from organizations accredited by the
ACCME .
Heather McPhillips, MD, MPH, FAAP
Assistant Professor and Associate Residency Director
Dept. of Pediatrics, University of Washington
Children’s Hospital and Regional Medical Center
Seattle, Washington
Medication Safety in
Ambulatory Pediatrics
Heather McPhillips, MD, MPH
University of Washington, Department of Pediatrics
Funding Source:
Agency for Healthcare Quality and Research
Collaborators:
Robert Davis, Christopher Stille, Marlene Miller, Rainu Kaushal, Dave
Smith, John Pearson, John Stull, Susan Andrade, Jerry Gurwitz &
The HMO Research Network CERT
Objectives
• Epidemiology of medication errors in ambulatory care

What do we know about medication errors in children
specifically in the outpatient setting?
• Known risk factors for medication errors

What are barriers to error-free prescribing to children?

Which children are at highest risk for errors?
• Strategies to reduce or eliminate medication errors in
ambulatory settings

What is known and where does future work need to focus?
Medication Safety in Children
• Children are seen by physicians often and
receive medication in up to 60% of these visits.
• Medication errors are common and can occur at
any step in the process
 Prescribing errors (dose, drug, allergy)
 Dispensing errors (formulation, instructions)
 Administration errors (dose, timing, others)
Objective #1
• Epidemiology of medication errors in ambulatory care

What do we know about medication errors in children
specifically in the outpatient setting?
• Known risk factors for medication errors

What are barriers to error-free prescribing to children?

Which children are at highest risk for errors?
• Strategies to reduce or eliminate medication errors in
ambulatory settings

What is known and where does future work need to focus?
Medication Errors in the ED
Kozer et al (Pediatrics, 2002)
• Retrospective review of medication errors in charts during
12 randomly selected days in emergency department
• Prescribing errors in 10% of charts



Only counted errors 20% or more outside of dosing range
Analgesics, antibiotics, antihistamines, asthma drugs most
likely involved
Highest risk in trainees at beginning of year and seriously ill
patients
Sedation Errors
Cote et al (Pediatrics, 2000)
• Examined 95 adverse sedation events (ASEs)

2/3 resulted in death or permanent injury
• Sedation for dental procedures accounted for 32 ASEs
• Medication overdoses, multiple sedatives, improper
administration and inadequate monitoring contributed to
serious errors
• Nearly ½ ASEs occurred outside the hospital setting (home,
dental office, clinic, car)
Administration Errors
• Errors in administration of medications to children by their
caregivers are common


As few as 30% of parents correctly administer proper dose
of acetaminophen to their child
Even when parents provided with correct dosing information
and child’s weight, correct dose given 40% of the time
• Frush et al (Archives of Pediatrics, 2004): Significantly
less error associated with simplified color-coded
information sheet and color-coded dosing syringe

50% conventional vs 92% color-coded given correct dose
Outpatient Chemotherapy for ALL
Taylor et al (Cancer, 2006)
• Reviewed chemotherapy at clinic visit over twomonth period for 69 patients prescribed 172 drugs
• Identified 17 medication errors in 13 children (19%)
• Administration errors were most common, followed
by prescribing errors
Potential Ambulatory Dosing Errors
McPhillips et al (Journal of Pediatrics, 2005)
• Examined potential dosing errors in new outpatient
prescriptions for 22 common medications at 3 HMOs
• Potential dosing errors occurred in 280 of 1,933
(15%) of prescriptions
 8% potentially overdosed
 7% potentially underdosed
Dosing Variation Mg/Kg/Day
(Children < 35kg, N = 1,050 Dispensings)
Class of Drug
%RDD
%< MinRDD
%>MaxRDD
Total
67
21
12
Analgesics
79
3
18
Asthma/Allergy
57
26
17
Behavioral
59
25
16
Antibiotics
81
16
4
Anti-epileptics
70
27
3
McPhillips et al, Journal of Pediatrics, 2005
Objective #2
• Epidemiology of medication errors in ambulatory care

What do we know about medication errors in children
specifically in the outpatient setting?
• Known risk factors for medication errors

What are barriers to error-free prescribing to children?

Which children are at highest risk for errors?
• Strategies to reduce or eliminate medication errors in
ambulatory settings

What is known and where does future work need to focus?
Challenges in Pediatric Prescribing
1. Pediatric prescribing is complex
2. Off-label medication use is common
3. Lack of standardization of recommended doses
4. Lack of guidelines regarding use of adult dosing
regimens
Prescribing is Complex
(1) An accurate weight must be obtained and correctly
transcribed (pounds or kilograms)
(2) In the course of a brief visit, the prescriber then must:
• convert pounds to kilograms
• make rapid weight-based calculations to determine
daily dose
• divide daily dose into multiple doses to obtain the
appropriate frequency for the medication
• choose the correct preparation and concentration
(liquid, chewables, tablets) of the medicine
• Determine the amount of liquid/tablet to be taken for
individual dose
Prescribing is Complex
(3) Communication with the parent or caregiver often will
occur without the medication present
(4) The prescription must be legible and correctly interpreted
by the pharmacist
(5) The pharmacist must dispense the appropriate
medication in its appropriate formulation labeled with the
appropriate dose and frequency.
Off-label Prescribing is Common
• Top 100 drugs dispensed to 2 million HMO members (HMO
Research Network CERT)
 40 have no labeling for children
 32 have some labeling restrictions
• Study examining prevalence of off-label use (1999-2001)
 13% of children <17 years dispensed off-label medication
 25% of children <2 years dispensed off-label medication
• Off-label medications increase risk of Adverse Drug Events
(ADEs)
• Less information available about appropriate doses—less
standardization
Recommended Doses Can Differ
Source
Recommended pediatric dose
for oxycodone
Harriet Lane Handbook
0.2 to 0.9 mg/kg/day q 4-6 hours
HMO Formulary
No weight-based dose provided.
Children’s Hospital Formulary 0.2 to 1.6 mg/kg/day q 3-4 hours
No Clear Rules about Adult Dosing
• No standard for when to switch from weight-based
dosing (pediatric) to daily dosing (adult)
• Some medications provide both weight-based and
age-based dosing (how do you choose?)
• Difficult to determine potential errors
• Unclear if clinically relevant
For example: amoxicillin
6 year-old 40kg male with otitis failed conservative therapy
Dr. Smart would like to treat with 90 mg/kg/day divided bid
Appropriate pediatric dose:
Appropriate adult dose:
3600 mg/day (1800mg bid)
2000 mg/day (1000 bid)
Potential overdose??
Potential underdose??
Risky Situations
Medications Prone to Error
(N = 2,028 Dispensings)
Class of Drug
% RDD
% UD
% OD
Total
87
6
7
Analgesics
86
prn
14
Asthma/Allergy
89
prn
11
Behavioral
88
5
7
Antibiotics
86
12
2
Anti-epileptics
80
20
1
McPhillips et al, Journal of Pediatrics, 2005
Children at Risk for Potential OD
Characteristic
Odds Ratio (95 CI)*
Age 0 to 3 years
1.6 (1.1 to 2.5)
Male
1.7 (1.1 to 2.4)
1 to 4 additional meds
1.4 (1.0 to 2.0)
5 or more additional meds
3.4 (1.4 to 8.0)
No clinic visit
1.8 (1.3 to 2.6)
*Adjusted for HMO, class of drug
McPhillips et al, Journal of Pediatrics, 2005
Objective #3
• Epidemiology of medication errors in ambulatory care

What do we know about medication errors in children
specifically in the outpatient setting?
• Known risk factors for medication errors

What are barriers to error-free prescribing to children?

Which children are at highest risk for errors?
• Strategies to reduce or eliminate medication errors in
ambulatory settings

What is known and where does future work need to focus?
Computerized Prescribing for
Children: Will it reduce error?
• CPOE may prevent substantial errors in children in
inpatient settings (ICU), but most systems are
currently home-grown
• Little is known about effectiveness in ambulatory
settings
• Few commercial systems have “standard” pediatric
decision support
Can CPOE Prevent Errors?
HMO with
CPOE
(N= 1,033)
HMOs with
hand-written
prescriptions
(N=994)
% Within
RDD
% UD
% OD
% Potential
Error
88
4
8
12
86
8
6
14
McPhillips et al, Journal of Pediatrics, 2005
Conclusions
• Medication errors are common in ambulatory pediatrics
and dispensing and prescribing errors are most common.
• Higher risk prescribing situations include
 young children
 children who have not been seen in clinic
 multiple medications at one time
 “prn” medications (analgesics, asthma meds)
• CPOE without decision support may not reduce
medication dosing errors in children.
Implications/Future Studies
• Electronic prescribing is a potentially successful
strategy but NOT without pediatric decision support
 Evidence in inpatient settings that CPOE reduces
medication dosing errors
• Complexity of pediatric prescribing leads to
complexity in designing electronic systems
• Simplified dosing regimens and standardization of
medication doses is needed
References
Kozer E, Scolnik D, Macpherson A, Keays T, Shi K, Luk T, Koren G.
Variables associated with medication errors in pediatric
emergency medicine. Pediatrics. 2002 Oct;110(4):737-42.
Kozer E, Scolnik D, MacPherson A, Rauchwerger D, Koren G.
Using a preprinted order sheet to reduce prescription errors in a
pediatric emergency department: a randomized, controlled trial.
Pediatrics. 2005 Dec;116(6):1299-302.
Cote CJ, Karl HW, Notterman DA, Weinberg JA, McCloskey C.
Adverse sedation events in pediatrics: analysis of medications
used for sedation. Pediatrics. 2000 Oct;106(4):633-44.
Li SF, Lacher B, Crain EF. Acetaminophen and ibuprofen dosing by
parents. Pediatr Emerg Care. 2000 Dec;16(6):394-7.
References
Simon HK, Weinkle DA. Over-the-counter medications.
Do parents give what they intend to give? Arch
Pediatr Adolesc Med. 1997 Jul;151(7):654-6.
Frush KS, Luo X, Hutchinson P, Higgins JN. Evaluation
of a method to reduce over-the-counter medication
dosing error. Arch Pediatr Adolesc Med. 2004
Jul;158(7):620-4.
Taylor JA, Winter L, Geyer LJ, Hawkins DS. Oral
outpatient chemotherapy medication errors in
children with acute lymphoblastic leukemia. Cancer.
2006 Sep 15;107(6):1400-1406.
References
McPhillips HA, Stille CJ, Smith D, Hecht J, Pearson J,
Stull J, Debellis K, Andrade S, Miller M, Kaushal R,
Gurwitz J, Davis RL. Potential medication dosing
errors in outpatient pediatrics. J Pediatr. 2005
Dec;147(6):761-7.
Gandhi TK, Weingart SN, Seger AC, Borus J, Burdick E,
Poon EG, Leape LL, Bates DW. Outpatient
prescribing errors and the impact of computerized
prescribing. J Gen Intern Med. 2005 Sep;20(9):83741.
Karen P. Zimmer, MD, MPH, FAAP
Assistant Professor
Johns Hopkins University
Baltimore, Maryland
Epidemiology and Intervention for
Pediatric Ambulatory Medication
Errors
Karen P. Zimmer, MD, MPH
Marlene R. Miller, MD, MSc
February 15, 2007
Safer Health Care for Kids Webinar
“Medication Safety in Ambulatory Care”
Goals
• Background
• Epidemiology
 Example: Analysis of a National Voluntary
Database (MEDMARX Database)
• Suggestions for Addressing Medication Errors
• Process Improvement
 Example: Narcotic Prescription Writer
Background on Medication Errors
•
Most common adverse event
IOM, 2000; Bates 1995
•
Most error prone step is prescribing
Lesar TS, 2002; Errors DB, 1999
•
Most errors occur as a result of both individual and
system failures
Leape LL et al. 1995; Reason J, 2000
•
Competent staff make mistakes
National Reporting System:
United States Pharmacopeia MEDMARX
• United States Pharmacopeia (USP)
 A practitioner-based organization that sets standards for
identity, strength, quality, purity, packaging, labeling, and
storage of therapeutic products.
• MEDMARX Database
 National, voluntary, internet-accessible error reporting
system
 Consists of 616 subscribing hospitals since January, 2005
 All are US hospitals
 All 50 states are represented
Study on Epidemiology
• Objective: To characterize and understand
medication errors in the outpatient clinic settings
 What types of medication errors occur?
 Where in the process do errors occur?
 What harm occurs?
MEDMARX
• Error reporting System
 Standardized
 Provides information on prescriptions as well as
medications in all types of ambulatory clinics
•
•
•
•
•
•
Error timing
Unit location
Phase of care in which error occurred
Error category
Cause of error
Medication Involved
MEDMARX Analysis
• Inclusion Criteria
 Queried database for all error reports from 2003
and 2004
 Involving patients < 19 years of age
 In all outpatient clinics (general and specialty
clinics)
 Error category limited to harm scores of Category
C-I (medical errors that reached the patient).
Results: All Errors
• Medication error reports (N=566)
 Involved
636 products (medications)
• Number of participating institutions
 154 (2003) and 162 (2004)
• Clinic-Type Distribution
 General Community Hospital Affiliate (52%)
 Stand alone Outpatient Clinic (28%)
 University Hospital Affiliate (11%)
• Age distribution
 Greatest for ages 1-3 (25.1%) and 12-18 (24.7%)
Results: All Errors
• Harm Score
 Over 2/3 of errors reached the patient but did not
cause harm (Category C)
 4% harmed the patient (Category E-I)
 Family/Patient discovered medication errors
almost 20% of the time.
Results: All Errors
• Error Node
 Definition: the phase of the medication process
where the error occurs
•
•
•
•
•
Administering (42%)
Prescribing phases (41%)
Dispensing (12%)
Transcribing/Documenting (4%)
Monitoring (1%)
0.0%
4%
A type not
determined
4%
Wrong
administration
technique/ wrong
route
5.0%
Wrong time
Wrong patient
10.0%
Omission Error
11%
Extra Dose
Drug prepared
incorrectly
Dosage Form
15.0%
Unauthorized/wrong
Prescribing Error
Improper
dose/quantity
Distribution of Error Types
for All Medications
25.0%
22%
20.0%
17%
14%
10%
9%
7%
3%
Results: Medications Involved
45
40
Percent
35
30
Immunologic(vaccines)
Antimicrobials
CNS meds (sedatives)
Respiratory Tract
(bronchodilators)
Dermatologic Agents
25
Hormones (Insulin)
20
Antihistamines
15
Gastrointestinal
10
Musculoskeletal
5
Therapeutic Nutrients
0
Ophthalmic
Otic agents
Age Distribution for
Vaccines Errors
24.7%
18.7%
25.1%
17.0%
14.5%
0-1 years
1-3 years
4-6 years
7-11 years
12-18 years
Error Distribution:
Top 5 Vaccines
12
Hepatitis B Vaccine, Recombinant
10
Influenza Virus Vaccine
9
Varicella Virus Vaccine Live
Diphtheria, Tetanus Toxoids, Acellular Pertussis
Adsorbed, Hepatitis B (Recombinant), and
Inactivated Poliovirus Vaccine
9
7
Pneumococcal Conjugate Vaccine
0
2
4
6
8
10
12
14
Vaccines: Types of Errors
30
27
Percents
25
20
17
17
15
14
8
10
5
0
tr
x
E
a
se
o
D
d
re
a
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D
g
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or
c
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ly
t
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/w
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e
iz
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o
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ug
r
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Im
pr
ity
t
an
u
/q
e
os
d
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o
ng
o
r
W
e
m
i
T
Age Distribution for
Antimicrobials Errors
18.6%
24.7%
22.7%
20.6%
13.4%
0-1 years
1-3 years
4-6 years
7-11 years
12-18 years
Antimicrobials: Distribution
Amoxicillin
28
Azithromycin
12
Ceftriaxone
10
Amoxicillin and
Clavulanate
7
0
5
10
15
Percents
20
25
30
pr
op
er
d
13
12
10
do
se
17
tra
15
18
Ex
20
tim
e
Percents
25
W
ro
ng
os
e/
qu
an
tit
Pr
y
es
c
rib
U
na
in
ut
g
ho
er
ro
riz
r
ed
/
D
w
ru
ro
g
ng
pr
dr
ep
ug
ar
ed
in
co
rr
ec
tly
Im
Antimicrobials: Error Types
30
Antimicrobials
27
Vaccines
21
17
14
12
11
8
5
2
0
Suggestions for Addressing
Medication Errors
• Error Prevention
 An evaluation framework in place
 Error-resistant systems are better than continuous education
 Providing redundant checks (increasing pharmacist
availability, different methods and persons at the various
stages of the medication process, 2 person, or using
software and a person)
• Leveraging Technology
• Standardized Practice
Lehmann CU and Kim GR, Clin Perintal 2005
Standardized Practice

Preprinted order sheet in a pediatric ED reduced errors
(OR 0.55, CI 0.34-0.90)
Kozer et al, Pediatrics 2005
• A modified outpatient prescription form was used to reduce
prescription errors in an adult population
Kenety and Littentber, Joint Commission on Accreditation of Healthcare
Organizations
• Electronic prescribing in an adult, ambulatory practice improved
throughput and increased patient satisfaction
Papshev,et al. Am J Manag Care 2007; Adubofour K, etl al. J of National
Med Assoc 2004
A Successful Intervention:
Example
Methods
• Method/Design
 Retrospective study December 2005 to October 2006
 Program implemented over several months
 Inpatient and outpatient settings
• Eligibility:
 General pediatric services and all surgical services
 Residents, fellows, nurse practitioners
• Narcotic prescriptions for all discharged patients from 0-18
years of age
• Users: 266 prescribers
 General pediatric (112, 42%)
 Orthopedic (38, 14%)
 Surgery (33, 12%
Distribution of Medications
Outcome of Prescription Attempts
4,995 Attempts
4,282 Attempts
Without Alerts
1,340 Incomplete
713 Attempts
With Alerts
2,942 Prescriptions
297 Overridden
3,239 Total Prescriptions
416 Incomplete
Results
• A prescription attempt with an alert was abandoned
58% of the time compared to 31% of the time if no
alert were generated (p<0.001).
• Alerts resulted in statistically significant increase in
abandoned prescription attempts.
Conclusion
• Identify vulnerabilities based on commonly used
medication types, age of patients and practice
environment
• Support systems that highlight potential errors can
alter behavior and prevent errors from being
completed
Take Home Points
• Dosing errors are common in ambulatory pediatrics
• Administering and prescribing are key error-prone
stages
• Narcotic analgesics pose high risk of harm
• Decision support is a crucial part of electronic
prescription writing systems.