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

96 W.H. Drummond et al.
Children’s Hospital implemented CPOE in December of 2002, becoming one of the
first children’s hospitals to use a commercial CPOE system. Shortly after implementation,
Upperman published a series of articles discussing pediatric CPOE at
Pittsburgh Children’s Hospital, outlining the Pediatric implementation methodology
and reporting the impact of Pediatric CPOE on medical errors and adverse
drug events. 47, 67 Over a 9 month study period he found that harmful adverse drug
events decreased from 0.05 events per 1,000 doses to 0.03 events per 1,000 doses
(p = 0.05). Based on this initial experience, it appeared that the Pittsburgh implementation
was modestly successful in decreasing ADEs.
When Dr. Han later published a follow-up article describing an unexpected
increase in PICU patient mortality after the Pittsburg CPOE implementation, the
report was surprising and made national headlines. 8 Han had analyzed a high risk
subset of ICU patients who were transported to the PICU, rather than studying the
whole inpatient Pediatric population or the whole PICU population. The subset
results showed a 3.86% increase in risk adjusted mortality after the CPOE system
was implemented; odds ratio of 3.28 [95% CI 1.94–5.55].
The negative findings of the Han paper were not solely related to technology.
In fact, the technology itself likely was a minor cause of the increased mortality.
Table 8.1 lists the confounding factors that played a prominent role in Pittsburg
PICU’s increased mortality.
Table 8.1 Confounding factors in Pittsburg PICU’s increased mortality
Implementation problem Assessment of risk Possible prevention strategy
Order entry
Unable to enter orders on
critically ill patients
prior to transport arrival
Order entry slow and
cumbersome (1–2 min
per order)
Physicians locked out of
system while pharmacy
processes order
No Pediatric ICU specific
order sets available at
“go live”
Delay in delivery of critical
medications and tests
likely to cause patient
harm
Slow order entry delays
delivery of care. Clinicians
are not at bedside when
interacting with
the computer
Delay in medications
administration may
cause harm
Physicians are unable
to respond to acute
deteriorations common
in transported PICU
admissions
Inefficient order entry
Inconsistent care
Slow, cumbersome order
entry in emergency
situations
Establish “virtual” beds so
admission orders can be
entered before arrival.
Use paper orders in emergency
situations
Streamline screen design
Place workstations at bedside
Build extensive order sets
Allow for simultaneous order
entry by several providers
incorporating concurrency
into the data structure
Evaluate clinical services’
emergency workflow and
build order sets that reduce
effort and streamline work
flow
(continued)