Moderator: Paul Sharek, MD, MPH, FAAP

1. The Role of Health Information Technology in Medication SafetyWednesday, April 25, 200712:00 – 1:00 p.m. EDT

2. Moderator: Paul Sharek, MD, MPH, FAAP Assistant Professor of Pediatrics, Stanford School of Medicine Medical Director of Quality Management Chief Clinical Patient Safety Officer Lucile Packard Children’s Hospital Palo Alto, California

3. This activity was funded through an educational grant from the Physicians’ Foundation for Health Systems Excellence.

4. 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 cost-effective 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 Activities. In accordance with these Standards, the following decisions will be made free of the control of a commercial interest: identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the CME activity. 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.

5. DISCLOSURES

6. DISCLOSURES

7. DISCLOSURES

8. 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.

9. OTHER CREDIT This webinar is approved by the National Association of Pediatric Nurse Practitioners (NAPNAP) for 1.2 NAPNAP contact hours of which 0.3 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 .

10. Rainu Kaushal, MD, MPH Associate Professor of Pediatrics and Public Health, Weill Medical College of Cornell University Director of Pediatric Quality and Safety, KCCH at NYPH New York, New York

11. The Role of Health Information Technology in Medication Safety April 25, 2007 12:00 – 1:00 p.m. EDT

12. Learning Objectives Upon completion of this activity, you will be able to: • Review the epidemiology of ambulatory medication safety in pediatrics. • Describe the role of health information technology in improving medication safety. • Utilize specific health information technology applications.

13. Historical Perspective • In 1925, 4 main types of adverse events identified for hospitalized patients: • Burns due to hot water • Delirious patients jumping from hospital windows • Accidents connected with hospital elevators • Mistakes in the use of drugs Aikens C. Study in the Ethics for Nurses. Philadelphia: Saunders; 1925

14. Patient Safety and Medical Errors Become a National Concern November 29, 1999

16. IOM Report: Preventing Medication Errors • One medication error per day per inpatient • Variation across institutions • At least 25% of injuries from medications are preventable • Annual preventable injuries from medications • 380,000-450,000 in hospitals for $3.5 billion • 800,000 in long-term care • 530,000 in Medicare ambulatory patients for $887 million

17. Preventing Medication Errors: Recommendations • Patient’s rights and enhancing consumer information • Utilizing HIT • Prescribing and transmission of all prescriptions electronically by 2010 • Appropriate clinical decision support • Adopt other appropriate technology (eMAR, bar coding, smart iv pumps) • Monitor for medication errors • Standards for HIT • More research • Pediatrics a prime focus area

18. Overview • Why medication errors occur in children • Pediatric medication error epidemiology • Inpatient • Outpatient • Prevention strategies • HIT • Safety and quality • Financial

19. Why medication errors occur in children • Weight based dosing • Stock medicine dilution • Ten fold errors • Decreased communication abilities • Inability to self-administer medications • Increased vulnerability of young, critically ill children • Immature renal and hepatic systems

20. Definitions Medication Errors ADEs Near Misses

21. Comparisons of Adult and Pediatric Inpatients PediatricsAdults** Orders reviewed 10,778 10,070 Medication errors 616 (5.7%) 530 (5.3%) Near Misses 115 (1.1%)35 (0.35%) * ADEs 26 (0.24%) 25 (0.25%) Preventable ADEs 5 (0.05%) 5 (0.05%) *p value <0.05 **Study performed at Brigham and Women’s Hospital in 1992 using similar methods Kaushal et al, JAMA 2001

22. Error Stage for Medication Errors

23. Near Misses in the NICU per 100 orders * * * * P<0.001 JAMA 2001;285;2114-20

24. Ambulatory Setting: Medication Errors • 2952 medication errors • 1.6 errors per patient • 1.3 errors per prescription • 521 (12%) rx inappropriate abbreviation • 1389 (64%) rx partially illegible

25. Preliminary Results For Six Office Practices

26. Stages Preventable ADEs Near Misses

27. Why Do Errors Occur? • Physician writes an order • Nursing, pharmacist, and clerical staff mechanisms are in place to carry out orders • What occurs in reality?

28. We deliver medications in hospitals in a manner that essentially hasn’t changed in 60 years. physician writes order pharmacist checks order/allergies nurse checks patient, drug, dose, route, time secretary transcribes nurse administers drug pharmacist checks drug interactions Is a double check necessary? nurse double checks pharmacy tech loads drawer pharmacy tech places drawer in delivery system Is drug administered via pump secretary faxes pharmacist receives fax nurse obtains drug from delivery system If order incorrect: multiple other steps pharmacist enter order nurse checks drug against med sheets

29. We deliver medications in hospitals in a manner that essentially hasn’t changed in 60 years. physician writes order pharmacist checks order/allergies nurse checks patient, drug, dose, route, time • Consider: What’s the error rate in each one of these steps - 5%, 1%, 0.1%, 0.01% secretary transcribes nurse administers drug pharmacist checks drug interactions Is a double check necessary? nurse double checks pharm. tech loads drawer pharm. tech places drawer in meditrol Is drug administered via pump secretary faxes pharmacist receives fax nurse obtains drug from meditrol If order incorrect: multiple other steps pharmacist enter order nurse checks drug against med sheets

30. Probability of success, each element: 0.95 0.99 0.999 0.9999 1 0.95 0.99 0.999 0.9999 25 0.28 0.78 0.96 0.998 # of elements 50 0.08 0.61 0.95 0.995 100 0.006 0.37 0.90 0.99 The Role of Complexity inPreventing Errors • Probability of Performing Perfectly:

31. No one makes an error on purpose. Lucian Leape

32. Everyone makes dumb mistakes every day.

33. No one admits an error if you punish them for it.

34. Error Reduction: Systems Approach • Culture of Safety • Non-punitive systems • Multidisciplinary error prevention • Involve parents and families • Executive walk rounds • Medication Safety Initiative • Strong, clear, visible attention to safety • Avoid fatigue • Minimize distractions • Independent double checks • 2nd checker will detect ~ 90% of errors made by first checker • HIT

35. How will HIT help? • Improve communication • What has been done and by whom • Improve accessibility • Paper records unavailable 1/3 of the time • Physicians spend 20-30% of their time searching for and organizing information • Require key pieces of information • Improve information retrieval • Impossible to store all needed clinical information in a physician’s head

36. How will HIT help? (cont) • “Just in time” decision support • Assist with calculations • Make the right thing the easiest to do • Perform checks in real-time • Assist with monitoring • Advance the quality agenda • Quality measurement • Low cost way to diffuse evidence-based best practices

37. Impact of HIT on Quality, Efficiency and Costs • 4 Benchmark institutions • Quality • Increased adherence to guidelines • Enhanced surveillance and monitoring • Medication errors • Efficiency • Decreased utilization of care • Financial Chaudhry B et al, Annals 2006

38. Types of HIT • EHR, Electronic health record • CPOE, Computerized physician order entry • Robots • Smart IV systems • Bar coding • Telemedicine • Automated drug delivery systems

39. CPOE: Low hanging fruit • Illegible handwriting • Incomplete information • Unacceptable Abbreviations • Lack of leading zeros • Inclusion of trailing zeros

40. Key Areas of Decision Support • Requiring complete orders • Default doses • Drug-allergy checking • DDI checking • Renal dosing • Geriatric dosing • Drug-lab checking • Dose ceilings

41. Handwriting example

42. “Corollary” order reminders reduce errors of omission • Target - corollary order pairs (n=87) • NSAID – creatinine level • Aminoglycoside – drug levels, creatinine • Warfarin – routine protimes • Intervention -- display reminder at time of ordering Overhage JAMIA 1997;4:364-375

43. Effect of alerts on compliance Overhage JAMIA 1997;4:364-375

44. Proportion of doses exceeding recommended maximum Teich Archives Int Med 2000;160:2741

45. Dosing appropriateness in patients with renal impairment Both results P < 0.001 Chertow JAMA 2001;286:2839-44

46. Effect of an antibiotic advisor All results statistically significant Costs, LOS also reduced Evans NEJM 1998;338:232-238

47. Effect of Changing Default Dosing Frequency for Ceftriaxone

48. NYPH -- Pediatric dosing decision support Computer suggests 300 mg every 8 hours for this patient; based on age and weight Evaluation • 32% of suggestions accepted exactly • Good reasons for not following • Subjectively, physicians like it (Killela B, et al; Pediatrics, 2007)

49. Results of Two Studies on Medication Error Prevention • CPOE reduced medication errors by 80% • CPOE reduced serious medication errors by 55% Bates et al, JAMA 1998

50. Evidence of Reduction in Errors • CPOE Pittsburgh Children’s • Harmful ADEs pre-CPOE 0.05/1000 doses • Post-CPOE 0.03/1000 doses (p=0.05). • CPOE prevents 1 ADE every 64 patient days Upperman et al. J Pediatr Surg 2005;40:57-59