August 9, 2010 | 2
As hospitals struggle to integrate electronic medical records, some have already instituted electronic drug ordering systems to help reduce prescription errors. But not all so-called computerized provider order entry (CPOE) systems are specially tuned to different patient populations. And while some can catch potentially dangerous drug-drug interactions for individuals, only one has been alerting providers when they are ordering something that could be dangerous for seniors.
"We have long known that certain commonly prescribed drugs can be harmful to older patients," Melissa Mattison, associate director of Hospital Medicine at Beth Israel Deaconess Medical Center (BIDMC) and a geriatrician, said in a prepared statement. "But because the majority of doctors have not been trained in geriatric medicine, they may not be aware of these risks."
A new study, published online August 9 in Archives of Internal Medicine, analyzes data from more than three years of BIDMC’s new CPOE program that provided warnings to health care workers ordering potentially harmful medicine for patients 65 years or older.
Some 60 percent of adverse drug events are initiated during the ordering step (as opposed to during administration), so minimizing poorly chosen drugs could go a long way in reducing these common medical errors, which occur during up to 40 percent of hospital stays, according to the paper.
"Our study found that when doctors were alerted that the drugs they were ordering could pose a danger to older hospital patients, the orders dropped almost immediately," said Mattison, who was the first author on the study.
After the new CPOE function was installed at BIDMC in 2005, the orders for potentially inappropriate medication (PIM) for older adults dropped—and stayed—some 20 percent lower than what they had been (down from an average of 11.6 a day to 9.9 a day).
"Many drugs commonly used today have not been tested in seniors or elderly patients," Mattison said. "As a result, a dose that is appropriate for a younger adult may lead to potentially harmful side effects in older individuals, who tend to metabolize medications more slowly."
The researchers based their warnings on the Beers Criteria, which is a list of dozens of drugs that are labeled as potentially inappropriate medication for older adults. The team wanted to avoid flagging too many drugs, as "too many ‘alerts’ just lead to user fatigue and people stop paying attention, which makes a warning system useless," Mattison said.
They chose to flag 18 common drugs that had safer alternative treatments for seniors. Providers could override the note by selecting a course of action (such as "Interaction noted, regimen clinically indicated, will closely monitor"). The system also warned prescribers about three common medications that might need a different dosage in older adults. And as a control class of drugs, the researchers did not create warnings for four popular treatments that did not have any recommended safer treatments.
The group found that although the orders of drugs with warnings dropped as soon as the system was put into place, there was no change in ordering quantities for the groups of drugs with different dosage recommendations or no warnings. The authors noted that because the hospital does not have electronic drug administration records, they were not able to track how much of the ordered drugs were actually given to patients—or how many medication-related adverse events occurred.
"We did not observe a substantial learning effect, in which one might hope to see a further reduction over time in the rate of ordering the PIMs," the authors noted in their paper. They attribute this to high annual turnover of people tasked with ordering medications at the hospital. But the researchers wrote that they are hopeful that systems like these can "change the way clinicians order medications and provide new opportunities to guide behavior."
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