RESUMEN
PURPOSE: We identify areas of overuse and underuse in the preoperative evaluation of patients undergoing mid urethral sling surgery. We also estimate the effect of overuse of preoperative testing on health care costs. MATERIALS AND METHODS: We conducted a retrospective review of women who underwent sling surgery with or without concomitant prolapse repair between 2012 and 2013. Physician orders for preoperative electrocardiogram, chest x-ray, basic metabolic panel, complete blood count, coagulation studies and urinalysis were classified as appropriate or inappropriate based on summary guidelines from the American Academy of Family Physicians. The additional costs of inappropriate tests were estimated using the 2014 Medicare clinical laboratory and physician fee schedules. RESULTS: A total of 101 women who underwent mid urethral sling surgery were identified and 346 preoperative tests were ordered. Overall 76% of coagulation profiles, 73% of complete blood counts, 47% of basic metabolic panels, 39% of chest x-rays and 21% of electrocardiograms ordered did not have an appropriate clinical indication. In addition, 6% of electrocardiograms, 22% of chest x-rays and 10% of urinalyses were not ordered despite an appropriate indication. The estimated charges of overused tests were $1,844.15 for the cohort, or $18 per patient. CONCLUSIONS: Preoperative testing is overused as well as underused in patients undergoing sling surgery. The greatest variation occurred with the use of electrocardiograms, chest x-rays and urinalysis. Poor adherence to national guidelines leads to increased health care costs and warrants increased awareness in following evidence-based guidelines.
Asunto(s)
Pruebas Diagnósticas de Rutina/economía , Pruebas Diagnósticas de Rutina/estadística & datos numéricos , Costos de la Atención en Salud , Uso Excesivo de los Servicios de Salud , Cuidados Preoperatorios/economía , Cuidados Preoperatorios/estadística & datos numéricos , Cabestrillo Suburetral , Incontinencia Urinaria de Esfuerzo/diagnóstico , Incontinencia Urinaria de Esfuerzo/cirugía , Adulto , Anciano , Femenino , Humanos , Persona de Mediana Edad , Estudios Retrospectivos , Incontinencia Urinaria de Esfuerzo/economíaRESUMEN
OBJECTIVES: The purpose of this work was to characterize medication errors and adverse drug events intercepted by a system of pediatric clinical pharmacists and to determine whether the addition of a computerized physician order entry system would improve medication safety. METHODS: The study included 16,938 medication orders for 678 admissions to the pediatric units of a large academic community hospital. Pediatric clinical pharmacists reviewed medication orders and monitored subsequent medication use. Medication errors and adverse drug events were identified by daily review of documentation, voluntary reporting, and solicitation. Each potentially harmful medication error was judged whether or not it was intercepted and, if not, whether it would have been captured by a computerized physician order entry system. RESULTS: Overall, 865 medication errors occurred, corresponding with a rate of 5.2 per 100 medication orders. A near-miss rate of 0.96% and a preventable adverse drug event rate of 0.09% were observed. Overall, 78% of potentially harmful prescribing errors were intercepted; however, none of the potentially harmful errors occurring at administration was intercepted and accounted for 50% of preventable adverse drug events. A computerized physician order entry system could capture additional potentially harmful prescribing and transcription errors (54%-73%) but not administration errors (0% vs 6%). CONCLUSIONS: A system of pediatric clinical pharmacists effectively intercepted inpatient prescribing errors but did not capture potentially harmful medication administration errors. The addition of a computerized physician order entry system to pharmacists is unlikely to prevent administration errors, which pose the highest risk of patient injury.
Asunto(s)
Sistemas de Entrada de Órdenes Médicas , Errores de Medicación/prevención & control , Pediatría , Servicio de Farmacia en Hospital/organización & administración , Niño , Humanos , FarmacéuticosRESUMEN
Many of the benefits of computerized physician order entry (CPOE) stem from its ability to support medical decision-making and error-reduction during patient care. This automated "intelligence" is typically represented by a network of rules. We describe a taxonomic representation of clinical decision-support rules in the context of developing and implementing a de novo CPOE and decision-support system. In our experience, this clinical rules taxonomy facilitated our implementation goals in the areas of physician acceptance and approval, rules construction and maintenance, and technical development and testing. This rules taxonomy may eventually be used to establish standards by which CPOE-based decision-support is measured.