Associate Director Center for Patient Safety Research and Practice, Brigham and Women's Hospital Boston.Director Quality and Safety, Harvard Medical School Center for Primary Care.
Purpose: The purpose of the BWH HIT-CERT was to leverage HIT for pharmacosurveillance, medication... more Purpose: The purpose of the BWH HIT-CERT was to leverage HIT for pharmacosurveillance, medication-related clinical decision support, and to identify new ways to utilize information coming from medication-related decision support. Moreover, we strove to advance our understanding of how providers are responding to medication-related decision support. Scope: Within the three BWH HIT-CERT subprojects, our team examined questions relating to appropriateness, safety, and efficacy across diverse patient populations. The projects covered multiple settings including outpatients, inpatients and recently discharged inpatients. Methods: We completed three research projects over a five-year period, each of which addressed one or more of the programmatic interest areas including patient safety, development and enhancement of tools, health care system interventions, and translation into practice or policy. The three subprojects involved: 1) leveraging new technologies to improve pharmacosurveillan...
Documenting the indication on prescriptions and dispensed medicines labels is not standard practi... more Documenting the indication on prescriptions and dispensed medicines labels is not standard practice in Australia. However, previous studies that have focused on the content and design of dispensed medicines labels, have suggested including the indication as a safety measure. The aim of this study was to investigate the perspectives of Australian consumers, pharmacists and prescribers on documenting the indication on prescriptions and dispensed medicines labels. Semi-structured interviews were conducted and mock-up of dispensed medicines labels were designed for participants. Consumers (n = 19) and pharmacists (n = 7) were recruited by convenience sample at community pharmacies in Sydney (Australia) and prescribers (n = 8), including two medical students, were recruited through snowballing. Thirty-four participants were interviewed. Most participants agreed that documenting the indication would be beneficial especially for patients who are forgetful or take multiple medications. Part...
Journal of the American Medical Informatics Association : JAMIA, Jan 22, 2018
To extract drug indications from a commercial drug knowledgebase and determine to what extent dru... more To extract drug indications from a commercial drug knowledgebase and determine to what extent drug indications can discriminate between look-alike-sound-alike (LASA) drugs. We extracted drug indications disease concepts from the MedKnowledge Indications module from First Databank Inc. (South San Francisco, CA) and associated them with drugs on the Institute for Safe Medication Practices (ISMP) list of commonly confused drug names. We used high-level concepts (rather than granular concepts) to represent the general indications for each drug. Two pharmacists reviewed each drug's association with its high-level indications concepts for accuracy and clinical relevance. We compared the high-level indications for each commonly confused drug pair and categorized each pair as having a complete overlap, partial overlap or no overlap in high-level indications. Of 278 LASA drug pairs, 165 (59%) had no overlap and 58 (21%) had partial overlap in high-level indications. Fifty-five pairs (20%...
Journal of general internal medicine, Jan 15, 2018
Drug-drug interaction (DDI) alerts in electronic health records (EHRs) can help prevent adverse d... more Drug-drug interaction (DDI) alerts in electronic health records (EHRs) can help prevent adverse drug events, but such alerts are frequently overridden, raising concerns about their clinical usefulness and contribution to alert fatigue. To study the effect of conversion to a commercial EHR on DDI alert and acceptance rates. Two before-and-after studies. 3277 clinicians who received a DDI alert in the outpatient setting. Introduction of a new, commercial EHR and subsequent adjustment of DDI alerting criteria. Alert burden and proportion of alerts accepted. Overall interruptive DDI alert burden increased by a factor of 6 from the legacy EHR to the commercial EHR. The acceptance rate for the most severe alerts fell from 100 to 8.4%, and from 29.3 to 7.5% for medium severity alerts (P < 0.001). After disabling the least severe alerts, total DDI alert burden fell by 50.5%, and acceptance of Tier 1 alerts rose from 9.1 to 12.7% (P < 0.01). Changing from a highly tailored DDI alerting...
ObjectiveMedication voiding is a computerised provider order entry (CPOE)-based discontinuation m... more ObjectiveMedication voiding is a computerised provider order entry (CPOE)-based discontinuation mechanism that allows clinicians to identify erroneous medication orders. We investigated the accuracy of voiding as an indicator of clinician identification and interception of a medication ordering error, and investigated reasons and root contributors for medication ordering errors.MethodUsing voided orders identified with a void alert, we conducted interviews with ordering and voiding clinicians, followed by patient chart reviews. A structured coding framework was used to qualitatively analyse the reasons for medication ordering errors. We also compared clinician-CPOE-selected (at time of voiding), clinician-reported (interview) and chart review-based reasons for voiding.ResultsWe conducted follow-up interviews on 101 voided orders. The positive predictive value (PPV) of voided orders that were medication ordering errors was 93.1% (95% CI 88.1% to 98.1%, n=94). Using chart review-based...
In this article we review current evidence on strategies to evaluate diagnostic error solutions, ... more In this article we review current evidence on strategies to evaluate diagnostic error solutions, discuss the methodological challenges that exist in investigating the value of these strategies in patient care, and provide recommendations for methods that can be applied in investigating potential solutions to diagnostic errors. These recommendations were developed iteratively by the authors based upon initial discussions held during the Research Summit of the 7th Annual Diagnostic Error in Medicine Conference in September 2014. The recommendations include the following elements for designing studies of diagnostic research solutions: (1) Select direct and indirect outcomes measures of importance to patients, while also practical for the particular solution; (2) Develop a clearly-stated logic model for the solution to be tested; (3) Use rapid, iterative prototyping in the early phases of solution testing; (4) Use cluster-randomized clinical trials where feasible; (5) Avoid simple pre-p...
Journal of the American Medical Informatics Association, 2017
Objective: Medication order voiding allows clinicians to indicate that an existing order was plac... more Objective: Medication order voiding allows clinicians to indicate that an existing order was placed in error. We explored whether the order voiding function could be used to record and study medication ordering errors. Materials and Methods: We examined medication orders from an academic medical center for a 6-year period (2006–2011; n = 5 804 150). We categorized orders based on status (void, not void) and clinician-provided reasons for voiding. We used multivariable logistic regression to investigate the association between order voiding and clinician, patient, and order characteristics. We conducted chart reviews on a random sample of voided orders (n = 198) to investigate the rate of medication ordering errors among voided orders, and the accuracy of clinician-provided reasons for voiding. Results: We found that 0.49% of all orders were voided. Order voiding was associated with clinician type (physician, pharmacist, nurse, student, other) and order type (inpatient, prescription,...
Journal of the American Medical Informatics Association : JAMIA, Mar 19, 2017
The study objective was to evaluate the accuracy, validity, and clinical usefulness of medication... more The study objective was to evaluate the accuracy, validity, and clinical usefulness of medication error alerts generated by an alerting system using outlier detection screening. Five years of clinical data were extracted from an electronic health record system for 747 985 patients who had at least one visit during 2012-2013 at practices affiliated with 2 academic medical centers. Data were screened using the system to detect outliers suggestive of potential medication errors. A sample of 300 charts was selected for review from the 15 693 alerts generated. A coding system was developed and codes assigned based on chart review to reflect the accuracy, validity, and clinical value of the alerts. Three-quarters of the chart-reviewed alerts generated by the screening system were found to be valid in which potential medication errors were identified. Of these valid alerts, the majority (75.0%) were found to be clinically useful in flagging potential medication errors or issues. A clinical...
Drug name confusion is a common type of medication error and a persistent threat to patient safet... more Drug name confusion is a common type of medication error and a persistent threat to patient safety. In the USA, roughly one per thousand prescriptions results in the wrong drug being filled, and most of these errors involve drug names that look or sound alike. Prior to approval, drug names undergo a variety of tests to assess their potential for confusability, but none of these preapproval tests has been shown to predict real-world error rates. We conducted a study to assess the association between error rates in laboratory-based tests of drug name memory and perception and real-world drug name confusion error rates. Eighty participants, comprising doctors, nurses, pharmacists, technicians and lay people, completed a battery of laboratory tests assessing visual perception, auditory perception and short-term memory of look-alike and sound-alike drug name pairs (eg, hydroxyzine/hydralazine). Laboratory test error rates (and other metrics) significantly predicted real-world error rates...
Purpose: The purpose of the BWH HIT-CERT was to leverage HIT for pharmacosurveillance, medication... more Purpose: The purpose of the BWH HIT-CERT was to leverage HIT for pharmacosurveillance, medication-related clinical decision support, and to identify new ways to utilize information coming from medication-related decision support. Moreover, we strove to advance our understanding of how providers are responding to medication-related decision support. Scope: Within the three BWH HIT-CERT subprojects, our team examined questions relating to appropriateness, safety, and efficacy across diverse patient populations. The projects covered multiple settings including outpatients, inpatients and recently discharged inpatients. Methods: We completed three research projects over a five-year period, each of which addressed one or more of the programmatic interest areas including patient safety, development and enhancement of tools, health care system interventions, and translation into practice or policy. The three subprojects involved: 1) leveraging new technologies to improve pharmacosurveillan...
Documenting the indication on prescriptions and dispensed medicines labels is not standard practi... more Documenting the indication on prescriptions and dispensed medicines labels is not standard practice in Australia. However, previous studies that have focused on the content and design of dispensed medicines labels, have suggested including the indication as a safety measure. The aim of this study was to investigate the perspectives of Australian consumers, pharmacists and prescribers on documenting the indication on prescriptions and dispensed medicines labels. Semi-structured interviews were conducted and mock-up of dispensed medicines labels were designed for participants. Consumers (n = 19) and pharmacists (n = 7) were recruited by convenience sample at community pharmacies in Sydney (Australia) and prescribers (n = 8), including two medical students, were recruited through snowballing. Thirty-four participants were interviewed. Most participants agreed that documenting the indication would be beneficial especially for patients who are forgetful or take multiple medications. Part...
Journal of the American Medical Informatics Association : JAMIA, Jan 22, 2018
To extract drug indications from a commercial drug knowledgebase and determine to what extent dru... more To extract drug indications from a commercial drug knowledgebase and determine to what extent drug indications can discriminate between look-alike-sound-alike (LASA) drugs. We extracted drug indications disease concepts from the MedKnowledge Indications module from First Databank Inc. (South San Francisco, CA) and associated them with drugs on the Institute for Safe Medication Practices (ISMP) list of commonly confused drug names. We used high-level concepts (rather than granular concepts) to represent the general indications for each drug. Two pharmacists reviewed each drug's association with its high-level indications concepts for accuracy and clinical relevance. We compared the high-level indications for each commonly confused drug pair and categorized each pair as having a complete overlap, partial overlap or no overlap in high-level indications. Of 278 LASA drug pairs, 165 (59%) had no overlap and 58 (21%) had partial overlap in high-level indications. Fifty-five pairs (20%...
Journal of general internal medicine, Jan 15, 2018
Drug-drug interaction (DDI) alerts in electronic health records (EHRs) can help prevent adverse d... more Drug-drug interaction (DDI) alerts in electronic health records (EHRs) can help prevent adverse drug events, but such alerts are frequently overridden, raising concerns about their clinical usefulness and contribution to alert fatigue. To study the effect of conversion to a commercial EHR on DDI alert and acceptance rates. Two before-and-after studies. 3277 clinicians who received a DDI alert in the outpatient setting. Introduction of a new, commercial EHR and subsequent adjustment of DDI alerting criteria. Alert burden and proportion of alerts accepted. Overall interruptive DDI alert burden increased by a factor of 6 from the legacy EHR to the commercial EHR. The acceptance rate for the most severe alerts fell from 100 to 8.4%, and from 29.3 to 7.5% for medium severity alerts (P < 0.001). After disabling the least severe alerts, total DDI alert burden fell by 50.5%, and acceptance of Tier 1 alerts rose from 9.1 to 12.7% (P < 0.01). Changing from a highly tailored DDI alerting...
ObjectiveMedication voiding is a computerised provider order entry (CPOE)-based discontinuation m... more ObjectiveMedication voiding is a computerised provider order entry (CPOE)-based discontinuation mechanism that allows clinicians to identify erroneous medication orders. We investigated the accuracy of voiding as an indicator of clinician identification and interception of a medication ordering error, and investigated reasons and root contributors for medication ordering errors.MethodUsing voided orders identified with a void alert, we conducted interviews with ordering and voiding clinicians, followed by patient chart reviews. A structured coding framework was used to qualitatively analyse the reasons for medication ordering errors. We also compared clinician-CPOE-selected (at time of voiding), clinician-reported (interview) and chart review-based reasons for voiding.ResultsWe conducted follow-up interviews on 101 voided orders. The positive predictive value (PPV) of voided orders that were medication ordering errors was 93.1% (95% CI 88.1% to 98.1%, n=94). Using chart review-based...
In this article we review current evidence on strategies to evaluate diagnostic error solutions, ... more In this article we review current evidence on strategies to evaluate diagnostic error solutions, discuss the methodological challenges that exist in investigating the value of these strategies in patient care, and provide recommendations for methods that can be applied in investigating potential solutions to diagnostic errors. These recommendations were developed iteratively by the authors based upon initial discussions held during the Research Summit of the 7th Annual Diagnostic Error in Medicine Conference in September 2014. The recommendations include the following elements for designing studies of diagnostic research solutions: (1) Select direct and indirect outcomes measures of importance to patients, while also practical for the particular solution; (2) Develop a clearly-stated logic model for the solution to be tested; (3) Use rapid, iterative prototyping in the early phases of solution testing; (4) Use cluster-randomized clinical trials where feasible; (5) Avoid simple pre-p...
Journal of the American Medical Informatics Association, 2017
Objective: Medication order voiding allows clinicians to indicate that an existing order was plac... more Objective: Medication order voiding allows clinicians to indicate that an existing order was placed in error. We explored whether the order voiding function could be used to record and study medication ordering errors. Materials and Methods: We examined medication orders from an academic medical center for a 6-year period (2006–2011; n = 5 804 150). We categorized orders based on status (void, not void) and clinician-provided reasons for voiding. We used multivariable logistic regression to investigate the association between order voiding and clinician, patient, and order characteristics. We conducted chart reviews on a random sample of voided orders (n = 198) to investigate the rate of medication ordering errors among voided orders, and the accuracy of clinician-provided reasons for voiding. Results: We found that 0.49% of all orders were voided. Order voiding was associated with clinician type (physician, pharmacist, nurse, student, other) and order type (inpatient, prescription,...
Journal of the American Medical Informatics Association : JAMIA, Mar 19, 2017
The study objective was to evaluate the accuracy, validity, and clinical usefulness of medication... more The study objective was to evaluate the accuracy, validity, and clinical usefulness of medication error alerts generated by an alerting system using outlier detection screening. Five years of clinical data were extracted from an electronic health record system for 747 985 patients who had at least one visit during 2012-2013 at practices affiliated with 2 academic medical centers. Data were screened using the system to detect outliers suggestive of potential medication errors. A sample of 300 charts was selected for review from the 15 693 alerts generated. A coding system was developed and codes assigned based on chart review to reflect the accuracy, validity, and clinical value of the alerts. Three-quarters of the chart-reviewed alerts generated by the screening system were found to be valid in which potential medication errors were identified. Of these valid alerts, the majority (75.0%) were found to be clinically useful in flagging potential medication errors or issues. A clinical...
Drug name confusion is a common type of medication error and a persistent threat to patient safet... more Drug name confusion is a common type of medication error and a persistent threat to patient safety. In the USA, roughly one per thousand prescriptions results in the wrong drug being filled, and most of these errors involve drug names that look or sound alike. Prior to approval, drug names undergo a variety of tests to assess their potential for confusability, but none of these preapproval tests has been shown to predict real-world error rates. We conducted a study to assess the association between error rates in laboratory-based tests of drug name memory and perception and real-world drug name confusion error rates. Eighty participants, comprising doctors, nurses, pharmacists, technicians and lay people, completed a battery of laboratory tests assessing visual perception, auditory perception and short-term memory of look-alike and sound-alike drug name pairs (eg, hydroxyzine/hydralazine). Laboratory test error rates (and other metrics) significantly predicted real-world error rates...
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