Pediatric Informatics: Computer Applications in Child Health (Health ...

94 W.H. Drummond et al.
needs require tailored designs and implementations. Epidemiology of Adverse Drug
Events (ADEs) in children reveals that most events originate at the drug ordering
4, 8–12, 39–42
stage, with the smallest and most critically ill patients at highest risk.
Dosing errors are extremely common in pediatrics. Children less than 2 years of
age and ICU patients are particularly susceptible. 39, 40 Given this evidence, it is easy
to understand why people believe that CPOE has potential for stopping these errors
at the source. Medical centers often implemented emerging technology in an urgent
fashion in the hopes to reduce medical errors and improve outcomes.
Initial studies of CPOE were promising, but few addressed the complex sociotechnical
challenges involved in a successful pediatric implementation. A study of
an adult population showed that CPOE alone decreased incidence of medication
errors by 64%; CPOE with clinical decision support can decrease error rates by
83%. 43 These successes must be put into perspective: Medication events most likely
prevented by CPOE such as illegible orders are also least likely to cause real patient
harm in a paper order environment, diminishing the effectiveness of CPOE. One
study suggested that pediatric CPOE system could have prevented 76% of potentially
harmful medication errors. 41 The Ohio State University showed that CPOE
dramatically improves operational efficiency, pharmacy turnaround times, and radiology
procedure completion times. 44 Similar operational improvements in the NICU
increased efficiency in delivering essential therapies to critically ill newborns. 45
The primary impetus for implementing pediatric CPOE remains patient safety
and not efficiency or cost reduction. Several pediatric inpatient studies reported
decreases in serious Adverse Drug Events (ADEs) and medication errors after the
implementation of CPOE. 42, 46–48 A study of pediatric ICU patients found a 95%
reduction in medication errors and a 40% reduction in potential ADEs. 48, 49 Although
this literature is encouraging, very few studies have looked at direct clinical outcome
measures such as mortality to assess the true impact of CPOE on pediatric patients.
When the 1999 Institute of Medicine (IOM) report concluded that between
44,000 and 98,000 people die each year from iatrogenic injury, physicians started
seeking innovative ways to improve the safety of patients, including children. 49
Several investigators concluded that deaths might be decreased by lowering the rate
of potential Adverse Drug Events (ADEs). 50–52 Similar to drug studies, most of the
initial safety literature focused on adults, so early findings were not easily generalized
to Pediatric populations. Until the Scenario B publications, CPOE research was
limited to mainly “home-grown,” CPOE utilities, 53–55 as opposed to commercially
purchased, essentially free-standing systems, “interfaced” to connect to older
“core” hospital information systems. The need to build interfaces generates a novel
problem space. Interfaces present software-based speed and accuracy problems
(e.g. decimal place and data type transforms, matching of catalogues).
Despite the lack of data on Pediatric systems and commercial systems, in 2003
an American Academy of Pediatrics (AAP) Policy Statement on the prevention
of medication errors officially recommended the use of “computerized systems”
wherever feasible. 56 More recently the IOM encouraged use of CPOE, clinical
decision support, bar coding, and smart pumps in all care settings to help prevent
medication errors. 57 These mandates have prompted physician practices and