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Lori Chen

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  • OS01 - Implementation: Futuristic Thinking (ID 3)

    • Event: e-Health 2017 Virtual Meeting
    • Type: Oral Session
    • Track: Clinical and Executive
    • Presentations: 1
    • Coordinates: 6/05/2017, 04:00 PM - 05:30 PM, Room 201CD
    • OS01.04 - Implementing a New Dose Range Checking Solution at SickKids Hospital (ID 44)

      Lori Chen, Pharmacy, The Hospital for Sick Children; Toronto/CA

      • Abstract
      • Slides

      Purpose/Objectives: Discuss development and implementation of a new dose range checking (DRC) solution optimized for tertiary paediatric hospital practice. Topics include creation of DRC decision rules for soft and hard alerts, approach to configuration, training and implementation, and monitoring new DRC solution for safety and efficacy.

      Methodology/Approach: SickKids has had computerized physician order entry with soft DRC alerts since 2008. The standard DRC tool lacked certain functionalities for tertiary paediatric practice, resulting in “wrong-dose” incident reports. In January 2016, SickKids assembled a multidisciplinary team (Medicine, Pharmacy, Information Services) to implement a new DRC solution with the electronic medical record (EMR) vendor (Allscripts). Compared to the standard DRC tool, the new solution had these key improvements: · Mandatory override reason · Concomitant soft and hard alerts · Set alerts, individually or in combination, by o Postmenstrual age o Weight o Age o Body surface area o Frequency · DRC stratified by clinical service Key components of implementing the new solution include: · Seek DRC approaches from other centres · Develop decision rules for setting soft and hard alerts · Obtain approval to implement hard stops and decision rules from various hospital committees: o Drugs and Therapeutics o Clinical Informatics Advisory Group o Medication Advisory Committee · Develop, test and implement new DRC solution with Allscripts · Develop reports to extract o Orders and doses entered in EMR by medication name o Alerts fired and overridden in EMR · Choose medications for go-live by o Identifying high alert medications without existing DRC o Selecting two “prototype” drugs (acetaminophen, tobramycin) · Establish DRC ranges for medications using decision rules, orders report and stakeholder input · Train users during July intake, through departmental in-services and via email communications o Pharmacists received in-depth training and support for hard-alert overrides · Evaluate dose range appropriateness using DRC alerts report and incident reports

      Finding/Results: Decision rules were developed: · Upper limits (percentage above usual dose) o High alert: 10% soft, 20% hard o Non-High alert: 15% soft, 30% hard · Minimum limit: 10-fold below usual low dose · Exceptions: titratable medications This was ratified at various hospital committees and helps logically set and justify DRC ranges. Soft and hard alerts were implemented for 19 medications in July 2016: · Acetaminophen · Aminophylline · Epinephrine · Epoprostenol · Esmolol · Labetalol · Magnesium sulphate · Nitroglycerin · Nitroprusside · Norepinephrine · Phentolamine · Phenylephrine · Potassium chloride · Potassium phosphate · Procainamide · Propofol · Sodium phosphate · Tobramycin · Vasopressin In the month post implementation, 1253 alerts fired for 993 items in the standard solution. Eleven alerts fired for 37 items in the new solution; 2 were hard alerts. This difference was driven by fewer nuisance alerts with the new solution. All override reasons in the new solution were reasonable.

      Conclusion/Implications/Recommendations: Consultation and education to front-line users, clear decision rules and new reports facilitated a successful launch, decreased nuisance alerts and improved patient safety. Next steps include monitoring and updating DRC settings and addition of medications to the new solution.

      140 Character Summary: SickKids sought to optimize its DRC tool in 6 months. Decision rules were developed & soft & hard alerts implemented, resulting in decreased nuisance alerts.

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