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

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when to suspend, discontinue, or maintain orders. Even with well-designed
policies, transfer processes are error-prone events.
Vended systems designed for use in the emergency department or operating
room (Specialty Systems) rarely have the temporal reasoning tools required to handle
movement from one hospital computer system to another, smoothly. Frequently,
they are not integrated with other hospital IT systems. Subsequently, knowledge
of orders may be lost, threatening safe patient care (e.g., the provider is unaware
of a medication administered in the operating room and orders another dose).
Developing a process for reconciling computerized orders in the peri-transport
period is extremely challenging for nearly all existing systems. Specialty systems
that are capable of integrating the many inpatient processes needed to manage
very sick patients quickly and accurately, remain nonexistent. “Work-arounds” that
involve time-consuming interaction of humans (nurses, pharmacists) with several
“specialty systems” can fall hopelessly behind he patient’s changing condition and
location, particularly at change of shift times.
8.3.4.3 Coupled or Linked Orders
Many types of medication administrations occur in proper temporal synchronization
for maximal benefit to the patient. CPOE implementation often leads to uncovering
of hidden temporal synchronization (separate tasks that are completed on paper
simultaneously seemingly as a single task). Breaking these combined orders apart
introduces novel, inherent workflow inefficiencies and increases complexity and
costs, especially in hospitals that have mixed electronic and paper based records.
For example, when an order is placed for a bronchodilator to treat an asthmatic
attack, a message must be sent to the pharmacy to dispense the drug, and a separate
parallel message must be sent to the Respiratory Therapist to administer the drug
to the patient. Drug administration requires dispensing of ordered devices for the
specific situation and patient. If any of these communications fail, there will be a
delay in care delivery. In a second example, incomplete implementation of medication
ordering systems can result in uncoupling of connected orders.
Many CPOE implementations exclude cytotoxic chemotherapeutic agents (a
common practice work-around with many CPOE systems due to the complexity of
chemotherapy agents), so these agents continue to be ordered on paper. Simultaneously,
ancillary drugs that must be ordered at the same time such as rescue medications,
anti-emetics, and hydration are managed by CPOE. This separation, which requires
a multiple orders (chemotherapy on paper, rescue medication on paper), wastes
care giver time, slows the order delivery to the bedside, and, most importantly, may
lead to patient harm due to risk of omission errors as a result of decoupling.
In an ideal world, all medication orders (delivery and administration) would
be maintained, temporally organized, routed, confirmed, and cross-checked with
a “completed delivery” message within a single CPOE system. Coupled orders
would remain linked in the system (such as chemotherapy and rescue medications).
Status of any particular order would be immediately accessible to all members of
the care team, as would be the current physical location of the patient (including