Quality Improvement in Pediatric Head Trauma with PECARN Rules Implementation as Computerized Decision Support.

BACKGROUND: For the 1.4 million emergency department (ED) visits for traumatic brain injury (TBI) annually in the United States, computed tomography (CT) may be over utilized. The Pediatric Emergency Care Applied Research Network developed 2 prediction rules to identify children at very low risk of clinically important TBI. We implemented these prediction rules as decision support within our electronic health record (EHR) to reduce CT. OBJECTIVE: To test EHR decision support implementation in reducing CT rates for head trauma at 2 pediatric EDs. METHODS: We compared monthly CT rates 1 year before [preimplementation (PRE)] and 1 year after [postimplementation (POST)] decision support implementation. The primary outcome was change in CT use rate over time, measured using statistical process control charts. Secondary analyses included multivariate comparisons of PRE to POST. Balancing measures included ED length of stay and returns within 7 days after ED release. RESULTS: There were 2,878 patients with head trauma (1,329 PRE and 1,549 POST) included. Statistical process control charts confirmed decreased CT rates over time POST that was not present PRE. Secondary statistical analyses confirmed that CT scan utilization rates decreased from 26.8% to 18.9% (unadjusted Odds Ratio [OR], 0.64; 95% Confidence Interval [CI], 0.53 -0.76; adjusted OR, 0.71; 95% CI, 0.58 -0.86). Length of stay was unchanged. There was no increase in returns within 7 days and no significant missed diagnoses. CONCLUSIONS: Implementation of EHR-integrated decision support for children with head trauma presenting to the ED is associated with a decrease in CT utilization and no increase in significant safety events.

Clinical and Geographic Characterization of 30-Day Readmissions in Pediatric Sickle Cell Crisis Patients.

BACKGROUND AND OBJECTIVES: Sickle cell disease (SCD) is a blood disorder affecting many US children that is often associated with hospital readmission. Although previous studies have reported on the clinical factors that influence readmission risk, potential geographic factors have not been fully investigated. The goal of this study was to investigate the importance of geographic risk factors and to confirm previously derived clinical risk factors that influence readmissions for SCD pain crises. METHODS: Retrospective analyses were performed on pediatric inpatients with sickle cell crises at a single center. Readmission rates and risk factors were assessed. Geospatial analysis was conducted on point variables that represented health service access, and multivariable logistic regression models were constructed. RESULTS: The study identified 373 patients experiencing sickle cell crises, with 125 (33.5%) having at least one 30-day readmission. Age (mean difference: 2.2 years; P<0.001), length of stay (median difference: 1 day; P<.001), admission pain score>7 of 10 (odds ratio [OR]: 2.21; P<0.01), discharge pain score>4 of 10 (OR: 2.098; P<.01), living within 5 miles of the center's main hospital (OR: 0.573; P=.04), and >3 hospital utilizations in the previous 12 months (OR: 5.103; P<.001) were identified as potential indicators of 30-day readmission risk. Logistic regression models for 30-day readmissions yielded similar results. CONCLUSIONS: Increased age, high admission and discharge pain scores, decreased length of stay, and increased hospital utilizations were found to be associated with an increased risk of readmission for sickle cell crisis. Patient's residence was also found to be a significant risk indicator, supporting the utility of geospatial analysis in assessing readmission risk.

Automated adverse event detection collaborative: electronic adverse event identification, classification, and corrective actions across academic pediatric institutions.

BACKGROUND: Historically, the gold standard for detecting medical errors has been the voluntary incident reporting system. Voluntary reporting rates significantly underestimate the number of actual adverse events in any given organization. The electronic health record (EHR) contains clinical and administrative data that may indicate the occurrence of an adverse event and can be used to detect adverse events that may otherwise remain unrecognized. Automated adverse event detection has been shown to be efficient and cost effective in the hospital setting. The Automated Adverse Event Detection Collaborative (AAEDC) is a group of academic pediatric organizations working to identify optimal electronic methods of adverse event detection. The Collaborative seeks to aggregate and analyze data around adverse events as well as identify and share specific intervention strategies to reduce the rate of such events, ultimately to deliver higher quality and safer care. The objective of this study is to describe the process of automated adverse event detection, report early results from the Collaborative, identify commonalities and notable differences between 2 organizations, and suggest future directions for the Collaborative. METHODS: In this retrospective observational study, the implementation and use of an automated adverse event detection system was compared between 2 academic children's hospital participants in the AAEDC, Children's National Medical Center, and Cincinnati Children's Hospital Medical Center. Both organizations use the EHR to identify potential adverse events as designated by specific electronic data triggers. After gathering the electronic data, a clinical investigator at each hospital manually examined the patient record to determine whether an adverse event had occurred, whether the event was preventable, and the level of harm involved. RESULTS: The Automated Adverse Event Detection Collaborative data from the 2 organizations between July 2006 and October 2010 were analyzed. Adverse event triggers associated with opioid and benzodiazepine toxicity and intravenous infiltration had the greatest positive predictive value (range, 47%- 96%). Triggers associated with hypoglycemia, coagulation disturbances, and renal dysfunction also had good positive predictive values (range, 22%-74%). In combination, the 2 organizations detected 3,264 adverse events, and 1,870 (57.3%) of these were preventable. Of these 3,264 events, clinicians submitted only 492 voluntary incident reports (15.1%). CONCLUSIONS: This work demonstrates the value of EHR-derived data aggregation and analysis in the detection and understanding of adverse events. Comparison and selection of optimal electronic trigger methods and recognition of adverse event trends within and between organizations are beneficial. Automated detection of adverse events likely contributes to the discovery of opportunities, expeditious implementation of process redesign, and quality improvement.

Hypoglycemia adverse events in PICUs and cardiac ICUs: differentiating preventable and nonpreventable events*.

OBJECTIVES: To describe the use of an adverse event detection system to identify, characterize, and categorize preventable versus nonpreventable hypoglycemia AEs in PICUs and cardiac ICUs. DESIGN: Retrospective observational study. SETTING: PICU and cardiac ICU of a tertiary pediatric hospital. SUBJECTS: All hypoglycemia triggers generated over a 3-year period. INTERVENTIONS: All hypoglycemia triggers generated via an electronic health record-driven surveillance system were investigated to determine if they represented a true adverse event and if that event was preventable or nonpreventable. Clinical and demographic variables were analyzed to identify characteristics of patients who developed a preventable or nonpreventable hypoglycemia adverse event. MEASUREMENTS AND MAIN RESULTS: There were 197 hypoglycemia adverse events in 90 patients. Thirty percent of the adverse events in the PICU and 36% of the adverse events in the cardiac ICU were characterized as preventable. Of the adverse events, 118 (59.9%) necessitated an intravenous dextrose bolus. No adverse events were associated with reporting of symptoms of hypoglycemia including apnea, altered mental status, or seizures. Events were more likely to be preventable (p < 0.001) if the patient was receiving only parenteral sources of nutrition (intravenous fluids or total parenteral nutrition). Controlling for weekends and holidays, adverse events associated with sole parenteral nutrition source had an increased odds ratio of 9.5 (95% confidence interval: 2.8-31.9) of being preventable. Stratifying by ICU, cardiac ICU events occurring on a weekend or holiday were more likely to be preventable (p = 0.001). Stratifying by unit and controlling for parenteral nutrition source, adverse events in the cardiac ICU occurring on weekends or holidays had an increased odds ratio of 11.6 (95% confidence interval: 2.7-50.2) of being preventable. CONCLUSIONS: Preventable hypoglycemia adverse events are associated with patients receiving sole parenteral sources of nutrition in both the PICU and cardiac ICU. In the cardiac ICU, there is an association between weekend and holiday time periods and the development of preventable hypoglycemia adverse events.

Nutritional immunomodulation in critically ill children with acute lung injury: feasibility and impact on circulating biomarkers.

OBJECTIVE: Respiratory failure caused by acute lung injury or acute respiratory distress syndrome is associated with significant morbidity in children. Enteral nutrition enriched with eicosapentaenoic acid, γ-linolenic acid and antioxidants (eicosapentaenoic acid + γ-linolenic acid) can safely modulate plasma phospholipid fatty acid profiles, reduce inflammation, and improve clinical outcomes in adults. There is little information regarding the use of enteral eicosapentaenoic acid + γ-linolenic acid to modulate plasma phospholipid fatty acid profiles in children. We sought to determine if continuous feeding of enteral nutrition containing eicosapentaenoic acid, γ-linolenic acid, and antioxidants was feasible in critically ill children with acute lung injury or acute respiratory distress syndrome. We further evaluated the impact of such an approach on the alteration of plasma phospholipid fatty acid concentrations. DESIGN: Prospective, blinded, randomized, controlled, multicenter trial. SETTING: PICU. PATIENTS: Twenty-six critically ill children (age 6.2 ± 0.9 yr, PaO2/FIO2 185 ± 15) with the diagnosis of acute lung injury or acute respiratory distress syndrome. INTERVENTIONS: Mechanically ventilated children received either eicosapentaenoic acid + γ-linolenic acid or a standard pediatric enteral formula. Clinical, biochemical, plasma fatty acid, and safety data were assessed at baseline, study days 4 and 7. MEASUREMENTS AND MAIN RESULTS: At baseline, there were no significant differences in the two study groups. Both groups met enteral feeding goals within 30 hrs and had similar caloric delivery. There were no differences in formula tolerance as measured by serum chemistries, liver and renal function, and hematology studies after 7 days of feeding either eicosapentaenoic acid + γ-linolenic acid or pediatric enteral formula. On study day 4 and 7, plasma phospholipid fatty acid profiles in the eicosapentaenoic acid + γ-linolenic acid group showed a significant increase in anti-inflammatory circulating markers. CONCLUSIONS: Providing enteral nutrition with eicosapentaenoic acid + γ-linolenic acid to critically ill children with lung injury was feasible and caloric goals were met within 30 hrs. This feeding protocol effectively modulated plasma phospholipid fatty acid concentrations to reflect an anti-inflammatory profile. This study provides data to inform future outcome studies using enteral eicosapentaenoic acid + γ-linolenic acid in children with lung injury.

Comparison of pandemic and seasonal influenza A infections in pediatric patients: were they different?

This retrospective cohort study revealed that the presence of pandemic H1N1 influenza resulted in a 77.7% increase of patient visits in the emergency department for influenza like illnesses and a 67.2% increase of hospital days in our hospital by comparing to a regular influenza season (2008-2009 season). However, median length of hospital stay was no different in either period (pandemic: 3 days versus seasonal: 4 days, P = 0.06). Except for the patients hospitalized for pandemic H1N1 influenza (n = 111) were older (median age: 4.7 years versus 1.6 years, P = 0.04) and tended to have pre-existing asthma (21.6% versus 9.0%, P = 0.07) than those hospitalized for seasonal influenza A infections (n = 44), this study found no significant difference between the two comparison groups with regards of other clinical and epidemiological features.

A phase III, open-label, single-arm study of tenecteplase for restoration of function in dysfunctional central venous catheters.

PURPOSE: To evaluate, in a phase III, single-arm study, the safety and efficacy of the thrombolytic agent tenecteplase in restoring function to dysfunctional central venous catheters (CVCs). MATERIALS AND METHODS: Pediatric and adult patients with dysfunctional CVCs were eligible to receive as much as 2 mL (2 mg) of intraluminal tenecteplase, which was left to dwell in the CVC lumen for a maximum of 120 minutes. If CVC function was not restored at 120 minutes, a second dose was instilled for an additional 120 minutes. RESULTS: Tenecteplase was administered to 246 patients. Mean patient age was 44 years (range, 0-92 y); 72 patients (29%) were younger than 17 years of age. Chemotherapy was the most common reason for catheter insertion. Restoration of CVC function was achieved in 177 patients (72%) within 120 minutes after the first dose. After instillation of a maximum of two doses of tenecteplase, CVC function was restored in 200 patients (81%), with similar frequencies in pediatric (83%) and adult (80%) patients. Adverse events (AEs) were reported in 31 patients (13%); fever (2%), neutropenia (1%), and nausea (0.8%) were most common. One serious AE, an allergic hypersensitivity reaction, was judged to be related to tenecteplase and/or a chemotherapeutic agent that the patient was receiving concurrently. CONCLUSIONS: Consecutive administration of one or two doses of tenecteplase into CVCs showed efficacy in the restoration of catheter function in patients with dysfunctional CVCs.

Recognizing hypoglycemia in children through automated adverse-event detection.

BACKGROUND: Automated adverse-event detection using triggers derived from the electronic health record (EHR) is an effective method of identifying adverse events, including hypoglycemia. However, the true occurrence of adverse events related to hypoglycemia in pediatric inpatients and the harm that results remain largely unknown. OBJECTIVE: We describe the use of an automated adverse-event detection system to detect and categorize hypoglycemia-related adverse events in pediatric inpatients. METHODS: A retrospective observational study of all hypoglycemia triggers generated by an EHR-driven surveillance system was conducted at a large urban children's hospital during a 1-year period. All hypoglycemia triggers were investigated to determine if they represented a true adverse event and if that event followed or deviated from the local standard of care. Clinical and demographic variables were analyzed to identify subpopulations at risk for hypoglycemia. RESULTS: Of the 1254 hypoglycemia triggers produced, 198 were adverse events (positive predictive value: 15.8%). No hypoglycemic adverse events were identified via the hospital's voluntary incident-reporting system. The majority of hypoglycemia-related adverse events occurred in the NICU (n = 123 of 198 [62.1%]). A total of 154 (77.8%) of the 198 adverse events hospital-wide and 102 (83%) of the 123 adverse events in the NICU occurred in patients who were receiving insulin therapy. CONCLUSIONS: Hypoglycemia is common in hospitalized children, particularly neonates and those who receive insulin. An EHR-driven automated adverse-event detection system was effective in identifying hypoglycemia in this population. Automated adverse-event detection holds great promise in augmenting the safety program of organizations who have adopted the EHR.

Helium/oxygen-driven albuterol nebulization in the management of children with status asthmaticus: a randomized, placebo-controlled trial.

OBJECTIVES: We investigated the effect of heliox-powered albuterol therapy on hospital length of stay and clinical status in children with moderate to severe status asthmaticus. DESIGN: Prospective, randomized, placebo-controlled trial. SETTING: Twenty-five-bed pediatric intensive care unit at an academic children's medical center. PATIENTS: Forty-two children (2-21 yrs of age) with moderate to severe status asthmaticus. INTERVENTIONS: Patients were randomized to receive either heliox-powered nebulized albuterol or air/oxygen-powered nebulized albuterol (placebo) until they were transitioned to albuterol delivered by a metered dose inhaler. MEASUREMENTS AND MAIN RESULTS: Clinical asthma scores were recorded on enrollment and every 4 hrs thereafter. Patients in the heliox group (n = 22) and the control group (n = 20) had similar ages (mean +/- sem: 88 +/- 9.9 vs. 98 +/- 11.1 months, respectively; p = .51), time to study enrollment (618 +/- 70.4 vs. 597 +/- 84.1 mins, respectively; p = .72), and clinical asthma scores at study entry (5.9 +/- 0.2 vs. 5.7 +/- 0.3, respectively; p = .72). There were no significant differences between groups in time to eligibility to hospital discharge (66.2 +/- 8.7 vs. 63.4 +/- 8.6 hrs, respectively; p = .61), time to clinical asthma score <3 (22 +/- 2.8 vs. 21.2 +/- 5.3 hrs, respectively; p = .27), or time to eligibility for intensive care unit discharge (34.4 +/- 6.8 vs. 33.3 +/- 8.2 hrs, respectively; p = .64). There were no significant differences in adverse events between groups. CONCLUSIONS: Despite the previously demonstrated effects of heliox on improved aerosol particle delivery into the distal airways, heliox-powered nebulized albuterol therapy for children admitted to the hospital with moderate to severe status asthmaticus does not shorten hospital length of stay or hasten rates of clinical improvement when compared with air/oxygen-powered nebulized albuterol.

Computerized Provider Order Entry with Pager Notification Improves Efficiency in STAT Radiographic Studies and Respiratory Treatments.

BACKGROUND: The use of computerized provider order entry (CPOE) has been widely linked to improvements in patient safety. We hypothesized that electronic routing of CPOE-generated orders through individual pagers would improve the efficiency of STAT radiographic studies and respiratory treatments. METHODS: The study was conducted in two periods before and after implementing pager notification of STAT orders. In the Baseline Period, CPOE-generated STAT orders were communicated to radiology technicians or respiratory therapists through the use of printed orders, manual paging and/or telephone communication. The time to process the order and deliver a radiology result or respiratory treatment was tracked. In the Intervention Period CPOE-generated STAT orders were electronically routed to the radiology technician's or respiratory therapist's pager. During both time periods, clinicians completed user satisfaction surveys. RESULTS: Using pager notification, there was a significant reduction in radiology technician arrival time (16.8±2.1 vs 7.9±0.7 mins, p<0.001). Similarly there was a significant reduction in the cumulative time required to capture the radiographic image, image availability in the picture archiving and communication system (PACS) and the verbal report from the radiologist (p<0.05). The time required in obtaining a preliminary or final radiographic written report and the total cycle times were not significantly reduced. For STAT respiratory therapy orders there was a significant reduction in the mean time from ordering to administration of respiratory therapy treatments (124.7±14.1 vs 49.8±11.4 minutes, p<0.01). Radiologists, respiratory therapists and ordering clinicians reported improved satisfaction after implementation of pager notification. CONCLUSION: Computer-generated orders for STAT radiographic studies and respiratory treatments can be carried out significantly faster through the use of direct pager notification. The implementation of this process has resulted in improved care delivery and widespread clinician satisfaction.

Post hoc analysis of calfactant use in immunocompromised children with acute lung injury: Impact and feasibility of further clinical trials.

OBJECTIVE: To assess the impact of calfactant (a modified natural bovine lung surfactant) in immunocompromised children with acute lung injury and to determine the number of patients required for a definitive clinical trial of calfactant in this population. DESIGN: Post hoc analysis of data from a previous randomized, control trial. SETTING: Tertiary care pediatric intensive care units. PATIENTS: All children, defined as immunocompromised, enrolled in a multicenter, masked, randomized, control trial of calfactant for acute lung injury conducted between July 2000 and July 2003. INTERVENTIONS: Patients received either an intratracheal instillation of calfactant or an equal volume of air placebo in a protocolized manner. MEASUREMENTS AND MAIN RESULTS: Eleven of 22 (50%) calfactant-treated patients died when compared with 18 of 30 (60%) placebo patients (absolute risk reduction 10.0%, 95% confidence interval [CI] -17.3, 37.3). Among the 23 patients with an initial oxygen index (OI) >/=13 and

Therapeutic application of intrapericardial tissue plasminogen activator in a 4-month-old child with complex fibropurulent pericarditis.

OBJECTIVE: To describe a young child with complex fibropurulent pericarditis who was successfully treated with intrapericardial recombinant tissue plasminogen activator. DESIGN: Individual case report. SETTING: Pediatric intensive care unit of a tertiary children's hospital. PATIENT: A 4-month-old Asian girl with Staphylococcus aureus septic shock who later developed a loculated fibropurulent pericardial effusion that was refractory to management with a subxiphoid percutaneous pericardial drainage catheter. INTERVENTIONS: Three doses of intrapericardial tissue plasminogen activator were administered at 12-hr intervals, allowed to dwell for 2 hrs, and subsequently drained via low continuous suction. MEASUREMENTS AND MAIN RESULTS: Immediately after intrapericardial tissue plasminogen activator was administered via a percutaneous pericardial drainage catheter, the patient had an increase in pericardial fluid drainage and resolution of a complex fibropurulent pericardial effusion. Pericardial fluid drainage ceased and then increased to 122 mL, 270 mL, and 80 mL of fluid, respectively, after each of the three doses of intrapericardial tissue plasminogen activator. Serial echocardiography confirmed the initial presence of the effusion, the subsequent loculated nature of the effusion, and ultimate resolution of the effusion after tissue plasminogen activator. The patient survived to hospital discharge without cardiac dysfunction. CONCLUSIONS: The fibrinolytic effect of tissue plasminogen activator therapy promotes the resolution of complex fibropurulent pericardial effusions refractory to traditional pericardial drainage via percutaneous catheter and suction. Use of intrapericardial tissue plasminogen activator may preclude the need for surgical intervention in fibropurulent pericarditis.

Lessons from a successful implementation of a computerized provider order entry system.

OBJECTIVES: The electronic health record (EHR) can improve patient safety, care efficiency, cost effectiveness and regulatory compliance. Cincinnati Children's Hospital Medical Center (CCHMC) has successfully implemented an Integrating Clinical Information System (ICIS) that includes Computerized Provider Order Entry (CPOE). This review describes some of the unanticipated challenges and solutions identified during the implementation of ICIS. METHODS: Data for this paper was derived from user-generated feedback within the ICIS. Feedback reports were reviewed and placed into categories based on root cause of the issue. Recurring issues or problems which led to potential or actual patient injury are included. RESULTS: NINE DISTINCT CHALLENGES WERE IDENTIFIED: 1) Deterioration in communication; 2) Excessive system alerts to users; 3) Unrecognized discontinuation of medications; 4) Unintended loss of orders; 5) Loss of orders during implementation; 6) Amplification of errors; 7) Unintentional generation of patient care orders by system analysts; 8) Persistence of specific patient care order instructions; 9) Verbal orders entered under the incorrect clinician. CONCLUSIONS: Unanticipated challenges are expected when implementing EHRs. The implementation plan for any EHR should include methods to identify, evaluate and repair problems quickly. While continued challenges with this complex system are expected, we believe that the EHR will continue to facilitate improved patient care and safety. The lessons learned at CCHMC will permit other institutions to avoid some of these challenges and design robust processes to detect and respond to problems in a timely fashion to ensure implementation success.

Alteplase for the treatment of central venous catheter occlusion in children: results of a prospective, open-label, single-arm study (The Cathflo Activase Pediatric Study).

PURPOSE: Alteplase is approved for use in the restoration of function to occluded central venous access devices (CVADs); however, there are few prospective studies in children. This study was undertaken to evaluate the safety and efficacy of alteplase in the treatment of CVAD occlusions in a pediatric population. MATERIALS AND METHODS: A prospective, multicenter, open-label, single-arm study evaluating a maximum of two doses (< or =2 mg per dose) of alteplase was performed in pediatric patients. Inclusion criteria included patient age less than 17 years with an occluded CVAD (single-, double-, and triple-lumen catheter or implanted port). Patients with hemodialysis catheters, those with known mechanical occlusion, or those considered at high risk for bleeding or embolization were excluded. Assessment of function was made 30 and 120 minutes (if required) after each dose. The primary objective of the study was to evaluate the safety of alteplase as measured by the incidence of intracranial hemorrhage (ICH); secondary objectives included the evaluation of specific targeted serious adverse events and efficacy of alteplase in the restoration of catheter function. RESULTS: A total of 310 patients (174 male patients, 136 female patients; mean age, 7.2 years; range, 0.04-18.3 y) were treated; 55 of the patients (17.7%) were younger than 2 years of age. No patients experienced ICH (95% CI, 0%-1.2%). Nine serious adverse events were noted in eight patients (2.6% incidence), two of which were attributed by the investigator to study drug administration (one case of sepsis and one case of a ruptured catheter lumen). The cumulative rate of restoration of CVAD function after serial administration of a maximum of two instillations of alteplase, each with a maximum dwell time of 120 minutes, was 82.9% (95% CI, 78.2%-86.9%). Similar rates of catheter function restoration were seen among all catheter types studied; there were no clinically meaningful differences among age or sex subgroups. CONCLUSION: The administration of alteplase is safe and effective for the restoration of function to CVADs in pediatric patients.

Impact of workflow-integrated corollary orders on aminoglycoside monitoring in children.

Computerized provider order entry (CPOE) and clinical decision support improve medication prescribing safety in adults. However, effective therapy for children requires dosing based on circulating medication levels. We examined the introduction of a computerized corollary order for aminoglycoside blood level monitoring. The study was divided into baseline (BP) and corollary order (CP) periods. In the CP, we implemented a workflow-integrated reminder to order blood levels and presented this to the clinician during each aminoglycoside ordering session. Appropriate laboratory monitoring was 128/159 (80.5%) courses in the BP and 146/177 (82.5%) courses in the CP. Thus introduction of the order did not significantly improve laboratory monitoring rates, nor did it result in a reduction in the rate of either toxic or subtherapeutic levels. However, aminoglycoside corollary orders may have an important role in institutions where pharmacists are not actively involved in monitoring therapy.

Inpatient verbal orders and the impact of computerized provider order entry.

OBJECTIVE: To describe the characteristics of verbal orders at a tertiary care children's hospital. STUDY DESIGN: Between August 2003 and January 2004, the computerized provider order entry (CPOE) system was evaluated for the characteristics of verbal orders. The rate of total orders represented by verbal orders and the rate of unsigned verbal orders were examined before, during, and after CPOE implementation. RESULTS: After CPOE implementation, a mean of 19,996 +/- 521 orders were generated weekly; of these, 2094 +/- 65 (10%) were verbal orders. The greatest rates of verbal orders were from psychiatry (74%) units and involved medication orders (38%; 790/2094). The greatest rates of medication verbal orders were psychotherapeutics (24%; 662/2697). Medical physicians had a larger rate of verbal orders than surgical physicians. The rates of verbal orders and unsigned verbal orders were reduced from 23% and 43% before CPOE implementation to 10% and 9% after implementation, respectively. CONCLUSIONS: Medication orders from physicians to nurses are the primary source of verbal orders in this tertiary care children's hospital. CPOE implementation significantly affected both verbal orders and the rate of unsigned verbal orders. This type of data is important for institutions aiming to decrease verbal orders and associated medical errors.