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

29 Understanding and Preventing Errors 377
levels to prevent toxicity. It is also common to administer folinic acid (Leucovorin)
which is an antidote to methotrexate and rescues healthy cells from methotrexate’s
toxic effects at the conclusion of therapy. We can examine how CPOE could be
used to develop an error-prevention strategy to prevent methotrexate toxicity.
CPOE applications could eliminate the task of cumbersome calculations for
body surface area by recalling height and weight data stored as a component of
other tasks. The application could also calculate appropriate methotrexate doses
thereby eliminating the task of that manual calculation. CPOE could also replace
the action of handwriting with the action of typing or selection from pick-lists.
This would be expected to have the result of improving legibility and preventing
certain handwriting interpretation errors. A multitude of functions could also be
facilitated electronically. For example, memory could be facilitate through the
use of order sets that combine orders for leucovorin and methotrexate level monitoring
along with the methotrexate order itself. Perception of potentially worrisome
laboratory values that might influence the medication ordering could be
facilitated through the use of alerts. Judgment could be facilitated by making drug
information, patient-specific information such as history or laboratory values, or
disease management protocols available at the point of ordering. The detection
of abnormalities such as a high methotrexate level could be improved by forcing
or automating the ordering of drug level monitoring at the time of medication
ordering. Rescue could be better assured if information systems also monitored
the results of drug level monitoring and provided alerts to appropriate caregivers
that the patient is in danger and requires immediate changes in therapy. Failures
to rescue could be reduced further were that information system to require a
timely response to the alert and escalate the notification to the next caregiver in
line should no response be received.
Evidence supports the potential benefits of informatics solutions in reducing
error. For example, computerized physician order entry systems can reduce medication
prescribing errors. 23–26 In addition, computerized decision support systems
can improve performance and diagnosis. 27–29 It is important to recognize, however,
that whereas it is possible to conceive, design, and build informatics solutions
intended to reduce error and improve performance, implementation does not
guarantee impact. Systems can fail to have their intended impact for any number
of reasons including users ignoring or rejecting computerized advice, 30 having difficulty
using the systems, 31 or challenges in integrating the tools into caregiver’s
workflow. 32 One strategy for optimizing the impact of informatics solutions is to
design and implement considering the failure modes of the information systems
themselves.
29.6.2 Failure Modes in Informatics Solutions
Although information systems may confer substantial benefits in reducing error,
they often substitute different tasks and functions than would be required in com-