Electronic alerts to improve management of heparin-induced thrombocytopenia.

Background: Heparin-induced thrombocytopenia (HIT) is a difficult clinicopathologic diagnosis to make and to treat. Delays in identification and appropriate treatment can lead to increased morbidity and mortality. Objectives: To use electronic health alert interventions to improve provider diagnosis and management of heparin-induced thrombocytopenia through guideline-based, accurate care delivery. Methods: This quality improvement initiative developed 3 electronic health record-based interventions at our 750-bed academic medical center to improve the initial management of suspected HIT between 2018 and 2021: 1. an interruptive alert to recommend discontinuation of active heparin products when signing a heparin-platelet factor 4 test (PF4) order, 2. integrated 4T score calculation in the heparin-PF4 test order, and 3. interruptive alert suggesting not to order heparin-PF4 tests when the 4T score is <4. Changes in practice were assessed over defined time periods pre and post each intervention. Results: Intervention 1 resulted in heparin discontinuation in more patients, with 65% (191 heparin orders/293 heparin-PF4 enzyme-linked immunosorbent assay tests) of cases continuing heparin prealert and only 54% (127 heparin orders/235 heparin-PF4 enzyme-linked immunosorbent assay tests) postinterruptive alert (95% CI 2.3-19.9; P = .015). Intervention 2 increased appropriate heparin-PF4 test ordering from 40.4% (110/272) preintervention to 79.1% (246/311) (95% CI 30.9-46.4; P < .00001) postintervention, with inappropriate PF4 ordering defined as testing when 4T score was <4. Intervention 3 did not lead to reduction in heparin-PF4 testing in the control group (96 inappropriate orders/402 total orders, 24%) compared to the randomized alert group (56 inappropriate orders/298 total orders; 19%) (95% CI -1.2 to 11.5; P = .13). Conclusion: Implementation of unique electronic health record interventions, including both diagnostic and management interventions, led to improved guideline-based, accurate care delivery with 4T score calculation and cessation of heparin for patients with suspected HIT.

How intervention studies measure the effectiveness of medication safety-related clinical decision support systems in primary and long-term care: a systematic review.

BACKGROUND: Medication errors and associated adverse drug events (ADE) are a major cause of morbidity and mortality worldwide. In recent years, the prevention of medication errors has become a high priority in healthcare systems. In order to improve medication safety, computerized Clinical Decision Support Systems (CDSS) are increasingly being integrated into the medication process. Accordingly, a growing number of studies have investigated the medication safety-related effectiveness of CDSS. However, the outcome measures used are heterogeneous, leading to unclear evidence. The primary aim of this study is to summarize and categorize the outcomes used in interventional studies evaluating the effects of CDSS on medication safety in primary and long-term care. METHODS: We systematically searched PubMed, Embase, CINAHL, and Cochrane Library for interventional studies evaluating the effects of CDSS targeting medication safety and patient-related outcomes. We extracted methodological characteristics, outcomes and empirical findings from the included studies. Outcomes were assigned to three main categories: process-related, harm-related, and cost-related. Risk of bias was assessed using the Evidence Project risk of bias tool. RESULTS: Thirty-two studies met the inclusion criteria. Almost all studies (n = 31) used process-related outcomes, followed by harm-related outcomes (n = 11). Only three studies used cost-related outcomes. Most studies used outcomes from only one category and no study used outcomes from all three categories. The definition and operationalization of outcomes varied widely between the included studies, even within outcome categories. Overall, evidence on CDSS effectiveness was mixed. A significant intervention effect was demonstrated by nine of fifteen studies with process-related primary outcomes (60%) but only one out of five studies with harm-related primary outcomes (20%). The included studies faced a number of methodological problems that limit the comparability and generalizability of their results. CONCLUSIONS: Evidence on the effectiveness of CDSS is currently inconclusive due in part to inconsistent outcome definitions and methodological problems in the literature. Additional high-quality studies are therefore needed to provide a comprehensive account of CDSS effectiveness. These studies should follow established methodological guidelines and recommendations and use a comprehensive set of harm-, process- and cost-related outcomes with agreed-upon and consistent definitions. PROSPERO REGISTRATION: CRD42023464746.

Adoption by clinicians of electronic order communications in NHS secondary care: a descriptive account.

BACKGROUND: Due to the rapid advancement in information technology, changes to communication modalities are increasingly implemented in healthcare. One such modality is Computerised Provider Order Entry (CPOE) systems which replace paper, verbal or telephone orders with electronic booking of requests. We aimed to understand the uptake, and user acceptability, of CPOE in a large National Health Service hospital system. METHODS: This retrospective single-centre study investigates the longitudinal uptake of communications through the Prescribing, Information and Communication System (PICS). The development and configuration of PICS are led by the doctors, nurses and allied health professionals that use it and requests for CPOE driven by clinical need have been described.Records of every request (imaging, specialty review, procedure, laboratory) made through PICS were collected between October 2008 and July 2019 and resulting counts were presented. An estimate of the proportion of completed requests made through the system has been provided for three example requests. User surveys were completed. RESULTS: In the first 6 months of implementation, a total of 832 new request types (imaging types and specialty referrals) were added to the system. Subsequently, an average of 6.6 new request types were added monthly. In total, 8 035 132 orders were requested through PICS. In three example request types (imaging, endoscopy and full blood count), increases in the proportion of requests being made via PICS were seen. User feedback at 6 months reported improved communications using the electronic system. CONCLUSION: CPOE was popular, rapidly adopted and diversified across specialties encompassing wide-ranging requests.

Quantifying and Reducing Errors in Vascular Imaging Examination Orders Through a Multistage Quality Improvement Intervention.

PURPOSE: The aims of this study were to quantify order error rates for vascular imaging examinations and to assess the effects of a multistage quality improvement intervention on those rates. METHODS: In this prospective, institutional review board-exempt project at a large academic quaternary care hospital, the authors aimed to quantify and reduce the order error rate by 50%. The authors analyzed 844 orders for all vascular imaging examinations placed before the intervention (July 19 to August 1, 2021, and September 13 to September 26, 2021), after an intervention in the cardiac surgery department consisting of a new customized order option in the electronic health record for routine preoperative patients (postintervention 1, February 28 to March 27, 2022); and after an educational and feedback campaign (postintervention 2, May 23 to June 5, 2022). Incorrect orders were identified by a radiology trainee during protocoling if the reasons for ordered examination and imaging examination were discordant and subsequently confirmed with the ordering provider. The primary outcome, order error rate, was compared across the project periods using the χ2 test and by ordering department using the χ2 and Fisher exact tests. RESULTS: The preintervention order error rate of 16% (50 of 306) decreased by 83% to 3% (10 of 353) at postintervention 1 (P < .001) and was durable at 3% (6 of 185) by project end. Chest CT with or without contrast constituted the majority of incorrect orders (44%, 22 of 50); "Pre-Op" was the most common examination reason (32% [16 of 50]). Cardiac surgery orderers were responsible for the most incorrect orders (32% [16 of 50]). All four most common ordering departments, including cardiac surgery, reduced their order error rates after the intervention (P < .001). CONCLUSIONS: Incorrect orders for imaging examinations can be reduced through targeted quality improvement interventions combining tailored electronic health record order options with education and feedback on practice habits.

Monitoring for adverse drug events of high-risk medications with a computerized clinical decision support system: a prospective cohort study.

Monitoring is recommended to prevent severe adverse drug events, but such examinations are often missed. To increase the number of monitoring that should be ordered for high-risk medications, we introduced a clinical decision support system (CDSS) that alerts and orders the monitoring for high-risk medications in an outpatient setting. We conducted a 2-year prospective cohort study at a tertiary care teaching hospital before (phase 1) and after (phase 2) the activation of a CDSS. The CDSS automatically provided alerts for liver function tests for vildagliptin, thyroid function tests for immune checkpoint inhibitors (ICIs) and multikinase inhibitors (MKIs), and a slit-lamp examination of the eyes for oral amiodarone when outpatients were prescribed the medications but not examined for a fixed period. The order of laboratory tests automatically appeared if alert was accepted. The alerts were hidden and did not appear on the display before activation of the CDSS. The outcomes were the number of prescriptions with alerts and examinations. During the study period, 330 patients in phase 1 and 307 patients in phase 2 were prescribed vildagliptin, 20 patients in phase 1 and 19 patients in phase 2 were prescribed ICIs or MKIs, and 72 patients in phase 1 and 66 patients in phase 2 were prescribed oral amiodarone. The baseline characteristics were similar between the phases. In patients prescribed vildagliptin, the proportion of alerts decreased significantly (38% vs 27%, P < 0.0001), and the proportion of examinations increased significantly (0.9% vs 4.0%, P < 0.0001) after activation of the CDSS. In patients prescribed ICIs or MKIs, the proportion of alerts decreased significantly (43% vs 11%, P < 0.0001), and the proportion of examinations increased numerically, but not significantly (2.6% vs 7.0%, P = 0.13). In patients prescribed oral amiodarone, the proportion of alerts decreased (86% vs 81%, P = 0.055), and the proportion of examinations increased (2.2% and 3.0%, P = 0.47); neither was significant. The CDSS has potential to increase the monitoring for high-risk medications. Our study also highlighted the limited acceptance rate of monitoring by CDSS. Further studies are needed to explore the generalizability to other medications and the cause of the limited acceptance rates among physicians.

Trends in computerized provider order entry: 20-year bibliometric overview.

Background: Drug-related problems (DRPs) can lead to serious health issues and have significant economic impacts on healthcare systems. One solution to address this issue is the use of computerized physician order entry systems (CPOE), which can help prevent DRPs by reducing the risk of medication errors. Objective: The purpose of this study is to provide an analysis on scientific production of the past 20 years in order to describe trends in academic publishing on CPOE and to identify the major topics as well as the predominant actors (journals, countries) involved in this field. Methods: A PubMed search was carried out to extract articles related to computerized provider order entry during the period January 1st 2003- December 31st 2022 using a specific query. Data were downloaded from PubMed in Extensible Markup Language (XML) and were processed through a dedicated parser. Results: A total of 2,946 articles were retrieved among 623 journals. One third of these articles were published in eight journals. Publications grew strongly from 2002 to 2006, with a dip in 2008 followed by an increase again in 2009. After 2009, there follows a decreasing until 2022.The most producing countries are the USA with 51.39% of the publication over the period by France (3.80%), and Canada (3.77%). About disciplines, the top 3 is: "medical informatics" (21.62% of articles), "pharmacy" (19.04%), and "pediatrics" (6.56%). Discussion: This study provides an overview of publication trends related to CPOE, which exhibited a significant increase in the first decade of the 21st century followed by a decline after 2009. Possible reasons for this decline include the emergence of digital health tools beyond CPOE, as well as healthcare professionals experiencing alert fatigue of the current system. Conclusion: Future research should focus on analyzing publication trends in the field of medical informatics and decision-making tools to identify other areas of interest that may have surpassed the development of CPOE.

Unsafe doctor-nurse interactions in the process of implementing medical orders: A qualitative study.

AIM: This study aimed to explore challenges faced by clinical nurses in the process of implementing medical orders. DESIGN: A qualitative study using inductive content analysis. METHODS: Semi-structured individual interviews were carried out with 17 participants including nurses, nurse managers and medical doctors who were purposefully selected. The collected data underwent inductive qualitative content analysis. RESULTS: The main research finding was the category of 'unsafe doctor-nurse interaction'. It included three subcategories: 'conflicts in documenting and executing orders', 'not accepting the nurse's suggestions for writing and correcting orders' and 'failure to accept the responsibility of orders by the doctor'. Challenges in the professional relationship between doctors and nurses cause mistrust and conflict. They also enhance nurses' concerns about professional and legal issues in the workplace and endanger patient safety.

Effect of computerized physician order entry inactivation to order complementary studies in an emergency department / [Efecto de la inactivación de las órdenes múltiples para solicitud de estudios complementarios en una central de emergencias.]

Introduction: The computerized provider order entry (CPOE) is a computing tool that could lead to unintended consequences despite its myriad benefits. We aimed to explore the effect of its inactivation on requests for complementary studies and the associated costs. Methods: Cross sectional study at the Emergency Department of Hospital Italiano de Buenos Aires, which included a consecutive sample of pre-intervention (January-February 2020) and post-intervention (2021) consultations. Using secondary bases, the variables included were administrative debits and their respective billing prices. Results: There were 27,671 consultations in 2020 with a total median value of $474, and 20,819 with $1,639 in 2021. After the analysis restricted to the area of ​​moderately complex clinics (excluding COVID-19 consultations), the following was found: a decrease in the median number of practices per consultation (median of 11 vs. 10, p=0.001), a decrease in the request for at least one laboratory practice (45% vs. 39%, p=0.001), without finding significant changes in global costs (median $1,419 vs. $1,081; p=0.122) or in specific laboratory costs (median $1,071 vs. $1,089, p=0.710). Conclusion: Despite inflation, a significant reduction in the number of practices was achieved and overall costs per consultation were maintained. These findings demonstrate the effectiveness of the intervention, but an educational intervention aimed at reminding the potential harm of overuse and the health costs of unnecessary studies will be necessary.

Introducción: La plantilla de órdenes múltiples es una herramienta informática que podría producir consecuencias inadvertidas pese a sus innumerables beneficios. Nos propusimos explorar el efecto de su inactivación sobre las solicitudes de estudios complementarios y los costos asociados. Métodos: Corte transversal en la Central de Emergencias de Adultos del Hospital Italiano de Buenos Aires, que incluyó muestra consecutiva de consultas pre-intervención (Enero-Febrero 2020) y post-intervención (2021). Mediante el uso de bases secundarias, las variables incluidas fueron los débitos administrativos y sus respectivos precios de facturación. Resultados: Hubo 27.671 consultas en 2020 con una mediana de valor total de 474$, y 20.819 con 1.639$ en 2021. Tras el análisis restringido al área de consultorios de moderada complejidad (excluyendo consultas por COVID-19), se encontró: una disminución en la mediana del número de prácticas por consulta (mediana de 11 vs 10, p=0,001), una disminución en la solicitud de al menos una práctica de laboratorio (45% versus 39%, p=0,001), sin encontrar cambios significativos en costos globales (mediana 1.419$ vs 1.081$; p=0,122) ni en costos específicos de laboratorio (mediana 1.071$ vs 1.089$, p=0,710). Conclusión: Pese a la inflación interanual, se logró una reducción significativa en el número de prácticas y se mantuvieron los costos globales por consulta. Estos hallazgos demuestran la efectividad de la intervención, pero serán necesarias medidas educativas que apunten al recordatorio de los potenciales daños en la sobreutilización, y los costos sanitarios de los estudios innecesarios.

Effects of a Computerized Prescriber Order Entry System on Pharmacist Prescribing.

Background: In Alberta, pharmacists are eligible to obtain additional prescribing authority (APA). At the University of Alberta Hospital, a transition was made from a paper-based prescriber order entry system to a computerized prescriber order entry (CPOE) system. Objectives: The primary objective was to quantify any change in pharmacist prescribing after CPOE implementation. The secondary objective was to compare the paper-based and CPOE systems in terms of drug schedule, order type, medication class, and the pharmacist's area of clinical practice. Methods: A retrospective comparative review of pharmacist orders was completed using 2-week periods of data from each of the paper-based order entry system and the CPOE system, spaced 1 year apart (in January 2019 and January 2020). Results: Pharmacists prescribed a mean of 3.76 (95% confidence interval 1.97-5.96) more orders per day within the CPOE system than in the paper-based system (p < 0.001). Schedule I medications accounted for a higher proportion of pharmacists' prescriptions in the CPOE system than in the paper-based system (77.7% versus 70.5%, p < 0.001). In terms of order type, discontinuation orders accounted for a much higher proportion of pharmacists' orders in the CPOE system than in the paper-based order entry system (58.0% versus 19.8%, p < 0.001). Conclusions: This study showed that a CPOE system resulted in more use of APA by pharmacists, with schedule I medications accounting for a higher proportion of pharmacists' prescriptions. With the CPOE system, pharmacists used their prescribing privileges to discontinue a higher proportion of orders than was the case with the paper-based system. Therefore, the CPOE system is a potential facilitator of pharmacist prescribing.

Contexte: En Alberta, les pharmaciens peuvent obtenir des pouvoirs de prescription supplémentaires (PPS). À l'hôpital de l'Université de l'Alberta, le système de saisie des ordonnances est passé d'un système sur papier à un système de saisie électronique des ordonnances (SSEO) par les prescripteurs. Objectifs: L'objectif principal consistait à quantifier tout changement dans la prescription des pharmaciens après la mise en place du SSEO. L'objectif secondaire visait à comparer le système sur papier et le SSEO en matière d'annexe des médicaments, de type d'ordonnance, de catégorie de médicament et de domaine de pratique clinique du pharmacien. Méthodes: Un examen comparatif rétrospectif des ordonnances des pharmaciens a été réalisé à l'aide de périodes de données de 2 semaines provenant de chacun des systèmes (papier et électronique), avec un intervalle d'un an (janvier 2019 et janvier 2020). Résultats: Les pharmaciens prescrivaient en moyenne 3,76 (intervalle de confiance à 95 % 1,97­5,96) ordonnances de plus par jour avec le SSEO qu'avec le système sur papier (p < 0,001). La part des ordonnances de médicaments de l'annexe I était plus importante avec le SSEO qu'avec le système sur papier (77,7 % contre 70,5 %, p < 0,001). En ce qui concerne le type d'ordonnance, la part des ordonnances de cessation était beaucoup plus élevée avec le SSEO qu'avec le système de saisie sur papier (58,0 % contre 19,8 %, p < 0,001). Conclusions: Cette étude a démontré un plus grand recours au PPS lorsque les pharmaciens utilisaient un SSEO et les médicaments de l'annexe I représentant une proportion plus élevée des ordonnances. Avec le SSEO, les pharmaciens ont utilisé leur pouvoir de prescription pour interrompre une part plus élevée d'ordonnances que ce n'était le cas avec le système sur papier. Le SSEO est donc un facilitateur potentiel de la prescription par les pharmaciens.

Safety risks and workflow implications associated with nursing-related free-text communication orders.

OBJECTIVE: We evaluated nursing-related free-text communication orders to identify potential safety hazards and describe patterns and scope of care domains addressed that may reveal preventable workarounds and potential gaps in electronic health record (EHR) functionality. MATERIALS AND METHODS: A retrospective analysis of free-text EHR-based communication orders sent to or by nurses providing inpatient care at a major academic health system. Using built-in EHR tools and selection criteria, 13 193 orders were extracted, including 1373 unique orders. Using the Clinical Care Classification system standardized framework, we classified content by care domain and identified unique requests within each order. We reviewed each order for error-prone textual features based on standard patient safety guidance. We describe the distribution of domains, co-occurrence when 2 domains were present, and common patterns. RESULTS: The 1373 unique orders included a single request (65.3%), 2 requests related to 1 or 2 domains (19%), or 3 or more requests (15.7%). No orders included terms on the Joint Commission's "Do Not Use" list. However, 13.6% of unique orders, and 16.7% of those related to medications, included error-prone symbols or abbreviations according to Institute for Safe Medication Practices guidance. Order content spanned 20 different care components but physical regulation, fluid volume, nutritional, safety, and medication were most frequently identified as single or co-occurring topics. Patterns were heterogenous. DISCUSSION: Free-text communication orders reveal workarounds, responses to upstream workarounds, and design constraints that should be further investigated. Remediation strategies are needed to reduce safety hazards and workflow impediments. CONCLUSIONS: Analysis of free-text communication orders revealed opportunities for improvement.

Implementation of a myasthenia gravis drug-disease interaction clinical decision support tool reduces prescribing of high-risk medications.

INTRODUCTION/AIMS: High-risk medication exposure is a modifiable risk factor for myasthenic exacerbation and crisis. We evaluated whether real-time electronic clinical decision support (CDS) was effective in reducing the rate of prescribing potentially high-risk medications to avoid or use with caution in patients with myasthenia gravis. METHODS: An expert panel reviewed the available drug-disease pairings and associated severity levels to activate the alerts for CDS. All unique alerts activated in both inpatient and outpatient contexts were analyzed over a two-year period. Clinical context, alert severity, medication class, and alert action were collected. The primary outcome was alert override rate. Secondary outcomes included the percentage of unique medication exposures avoided and predictors of alert override. RESULTS: During the analysis period, 2817 unique alerts fired, representing 830 distinct patient-medication exposures for 577 unique patients. The overall alert override rate was 85% (80.3% for inpatient alerts and 95.8% for outpatient alerts). Of unique medication-patient exposures, 19% were avoided because of the alert. Assigned alert severity of "contraindicated" were less likely to be overridden (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.32-0.56), as well as alerts activated during evening staffing (OR 0.69, 95% CI 0.55-0.87). DISCUSSION: Implementation of a myasthenia gravis drug-disease interaction alert reduced overall patient exposure to potentially harmful medications by approximately 19%. Future optimization includes enhanced provider and pharmacist education. Further refinement of alert logic criteria to optimize medication risk reduction and reduce alert fatigue is warranted to support clinicians in prescribing and reduce electronic health record time burden.

Standardized neonatal continuous infusion concentrations: A quality improvement initiative.

PURPOSE: Medication errors are a significant and preventable source of patient harm, especially in the neonatal population. Standardized infusion concentrations increase patient safety and streamline the workflow for pharmacists, nurses, and physicians. METHODS: Neonatal continuous infusion concentrations were standardized and implemented into the electronic health record using an automated order panel. Pre- and postimplementation data were collected to assess the impact of this quality improvement initiative. The primary endpoint was the proportion of neonatal intensive care unit infusion orders that were compatible with "bolus from infusion" functionality in the syringe pump. RESULTS: Before implementation, only 40% of eligible infusions were compatible with the "bolus from infusion" function, compared to 93% after implementation (P < 0.00001). Within the syringe pump, the ratio of total options to the number of concentrations per medication was reduced by 31%. CONCLUSION: Implementation of an order panel with defaulted standard infusion concentration selection improved workflow and optimized technology in the neonatal intensive care unit.

Association between cancer fatalism and optimistic attitudes in colorectal cancer patients and the moderating effects / 国际外科学杂志

Objective:To investigate the association between cancer fatalism and optimistic attitudes among colorectal cancer patients, and how the above linkage is moderated by the involvement of patients′ opinions, the family members′ opinions and the physicians′ opinions in treatment decision-making.Methods:A cross-sectional survey was conducted on 64 patients diagnosed with colorectal cancer and awaiting radical colorectal cancer surgery in the Department of General Surgery of Beijing Friendship Hospital Affiliated to Capital Medical University, from January 2021 to December 2021. There were 38 males and 26 females, aged (61.2±13.0) years from 30 to 84 years. Cancer fatalism, optimism attitudes, and the involvement of patients′ opinions, the family members′ opinions and the physicians′ opinions in treatment decision-making were assessed. The patients′ cancer fatalism beliefs were measured by the " Chance" subscale of the Form C of the Multidimensional Health Locus of Control (MHLC-C), optimism attitudes were assessed by the Chinese version of the revised Life Orientation Test (CLOT-R), and the influence of patients′, family members′, and physicians′ opinions in the medical decision-making process was measured by a self-designed single factor scale. Measurement data of normal distribution were expressed as mean±standard deviation ( ± s). Measurement data of skewed distribution were expressed as M( Q1, Q3). Spearman correlation analysis and Chi-square test was used to examine the association between the main outcome variable (patients′ optimistic attitudes) and demographic and clinical characteristics. Interaction was examined by hierarchical linear regression analysis combined with simple slope tests. Results:Cancer fatalism was negatively associated with patients′ optimistic attitudes ( r=-0.35, P<0.01). Optimistic attitude of patients was significantly and negatively correlated with the influence of family members′ opinions on medical decision-making ( r=-0.25, P<0.05). There were significant positive correlations between the influence of patients′ and family members′ opinions ( r=0.50, P<0.01), family members′ and physicians′ opinions ( r=0.67, P<0.01), and physicians′ and patients′ opinions ( r=0.38, P<0.01) in medical decision making. Hierarchical linear regression analysis showed a negative association between cancer fatalism and optimism ( β=-0.32, P=0.01). This association was further moderated by the involvement of family members′ opinions ( β=-0.56, P<0.01) and the involvement of physicians′ opinions ( β=-0.36, P=0.04) in medical decision-making. Simple slope tests revealed that the negative impact of fatalistic attitudes on patients′ optimism attitudes may be potentiated when family members′ opinions have high influence on medical decision-making, while the negative impact may be buffered to some extent when physicians′ opinions have high influence on medical decision-making. Conclusions:Cancer fatalism had a negative effect on patients′ optimism. The high influence of physicians in treatment decision-making buffered the negative effect of cancer fatalism on optimism; the high influence of family members in treatment decision-making potentiated the negative effect of cancer fatalism on optimism. In the process of doctor-patient communication and shared decision-making, for patients with strong fatalistic attitudes, consideration should be given to appropriately increasing direct informational communication between physicians and patients and reducing excessive family intervention in medical decision-making, so as to enhance patients′ autonomy for treatment, promote optimism, and reduce the negative effects of cancer fatalism.

Analysis of 197 cases of pentoxifylline injection and exploring supervision mode of rational drug use in hospitals / 中国临床药理学与治疗学

AIM: To analyze and evaluate the use of pentoxifylline injection in a hospital, and explore effective supervision mode, so as to provide some reference for clinical rational drug use. METHODS: A total of 197 inpatients with pentoxifylline injection who were discharged from October 2021 to June 2022 were randomly selected from HIS system. Referring to drug-label and collecting evidence-based medical evidence to judge the rationality of use of pentoxifylline injection in the hospital. RESULTS: Among the 197 medical records extracted, 140 medical records were unreasonable, accounting for 71.07% of the total medical records. Among them, 111 cases (79.29%) were no indication for use, 13 cases (9.29%) were off-label, 2 cases (1.43%) were inappropriate for indications, 13 cases (9.29%) were inappropriate for usage and dosage, and 1 case (0.71%) was inappropriate for solvent. CONCLUSION: The irrational use of pentoxifylline injection in this hospital is serious. It is necessary to standardize its clinical application through the intervention of smart pharmacy management mode, improving system, strengthening medication education and other ways.

How to Accommodate the Emotional Dimensions of Advance Care Planning Using Motivational Interviewing and Conditional Medical Orders.

Palliative care discussions offer a unique opportunity for helping patients choose end-of-life (EOL) treatments. These are among the most difficult decisions in later life, and protecting patients' ability to make these choices is one of healthcare's strongest ethical mandates. Yet, traditional approaches to advance care planning (ACP) have only been moderately successful in helping patients make decisions that lead to treatments concordant with their values. In particular, neglect of attention to the emotions that occur during consideration of the end of one's life contributes to patients' difficulty with engaging in the process and following through on decisions. To improve ACP outcomes, providers can address the patient's emotional experiences, and can use motivational interviewing as a way attend to elicit them and incorporate them into care planning. Applying personalizing emotion-attuned protocols like Conditional Medical Orders (CMO) also promotes this end.

Evaluation and Implementation of KIDs List Recommendations in a University Health System.

OBJECTIVE: The study aims to identify the rate of inappropriate prescribing per the Key Potentially Inappropriate Drugs in Pediatrics (KIDs) List versus total prescribing in patients at University of Missouri Health Care hospitals. METHODS: This retrospective study evaluated orders for patients treated at University of Missouri Health Care inpatient units or emergency departments with a KIDs List medication between September 1, 2019, and September 1, 2020, or a reported adverse event to one of these medications between September 1, 2015, and September 1, 2020. Patients were excluded if the patient safety report was related to a medication error rather than an adverse event. Safety measures assessed included age and weight filtering, dose-range checking, clinical decision support, and override availability. RESULTS: There were 39 inappropriate orders and 4 possible adverse events identified. A total of 8 of 33 medications (24%) had age and weight filtering in place for at least 1 order sentence, 1 of 38 (2.6%) had dose-range checking, no medications had an active clinical decision support alert, and 33 of 38 (87%) had availability on automated dispensing cabinet override. CONCLUSIONS: Use of KIDs List medications is appropriately low, but low levels of safety measure implementation leave pediatric patients vulnerable.

Can CPOE Based on Electronic Order Sets Cause Unintended Consequences (Expensive and Unnecessary Tests) at the Emergency Department?

Computerized Provider Order Entry (CPOE) systems may cause unintended consequences. This study aimed to describe the on-going system for CPOE order sets, and to explore an economic evaluation at the Emergency Department. First, we developed a costs dashboard which showed us the significant and excessive use of medical tests per consultation. We identified the top 10 most widely used and most expensive tests. Additionally we noticed that the labs seemed to continually increase. Then, we found that 27% of the consultations have at least one item of laboratory practice between January and February 2020, and this represents more than 80% of the consultation costs. Health care spending has reached epic proportions globally. We think that it is time to rethink effective strategies. Maybe it is time to deactivate/remove electronic order sets (EOSs) and the functionality to develop and create their own "private" order sets, in order to eliminate waste and inefficiencies.

Overriding Drug-Drug Interaction Alerts in Clinical Decision Support Systems: A Scoping Review.

Ineffective computerized alerts for potential Drug-Drug Interactions (DDI) is a longstanding informatics issue. Prescribing clinicians often ignore or override such alerts due to lack of context and clinical relevance, among various other reasons. In this study, we reveiwed published data on the rate of DDI alert overrides and medications involved in the overrides. We identified 34 eligible studies from sites across Asia, Europe, the United States, and the United Kingdom. The override rate of DDI alerts ranged from 55% to 98%, with more than half of the studies reporting the most common drug pairs or medications involved in acceptance or overriding of alerts. The high prevalance of alert overrides highlights the need for decision support systems that take user, drug, and institutional factors into consideration, as well as actionable metrics to better characterize harm associated with overrides.

Alerts in Clinical Decision Support Systems (CDSS): A Bibliometric Review and Content Analysis.

A clinical decision support system (CDSS) informs or generates medical recommendations for healthcare practitioners. An alert is the most common way for a CDSS to interact with practitioners. Research about alerts in CDSS has proliferated over the past ten years. The research trend is ongoing with new emerging terms and focus. Bibliometric analysis is ideal for researchers to understand the research trend and future directions. Influential articles, institutes, countries, authors, and commonly used keywords were analyzed to grasp a comprehensive view on our topic, alerts in CDSS. Articles published between 2011 and 2021 were extracted from the Web of Science database. There were 728 articles included for bibliometric analysis, among which 24 papers were selected for content analysis. Our analysis shows that the research direction has shifted from patient safety to system utility, implying the importance of alert usability to be clinically impactful. Finally, we conclude with future research directions such as the optimization of alert mechanisms and comprehensiveness to enhance alert appropriateness and to reduce alert fatigue.