Preventing medication errors due to unsafe electronic prescription transactions with just-in-time feedback

通过及时反馈防止因不安全的电子处方交易而导致的用药错误

• 批准号: 10709527
• 负责人: Corey A Lester
• 金额: $ 46.17万
• 依托单位: UNIVERSITY OF MICHIGAN AT ANN ARBOR
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-09-30 至 2025-09-29
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10709527
• 关键词: Preventing; medication; errors; due; unsafe

PROJECT SUMMARY Although electronic prescriptions (e-prescriptions) have improved patient safety in some ways, they have introduced new types of errors that can lead to significant harm to patients up to 4.39 million times each year. During e-prescription processing, medication errors occur when the medication prescribed by a physician is a different ingredient, strength, or dosage form compared to the medication dispensed by the pharmacist. Major reasons these unsafe e-prescription transactions exist include mismatching free-text drug descriptions with National Drug Codes (NDCs) and erroneous product selection in computer software used by prescribers and pharmacists. These unsafe e-prescription transactions are resulting in dangerous medication errors that may lead to significant patient harm. To systematically identify unsafe e-prescription transactions, we have developed a system, called SAVE-Rx, that uses e-prescription transaction data to automatically identify cases where the NDC prescribed does not match either the free-text drug description (i.e., an e-prescribing error) or the NDC of the medication dispensed by the pharmacy. Our system matches NDCs and free-text drug descriptions on the basis of medication ingredient, strength, and dosage form using standardized drug terminology from National Library of Medicine’s RxNorm. Unsafe e-prescription transactions are then reviewed by a safety team and communicated just-in-time to healthcare organizations, through existing e-prescription workflows, before they can cause harm to patients. Our long-term goal is to improve medication safety through the strategic use of automation in medication prescribing and dispensing workflows. The overall objective of this study is to determine the effect of implementing just-in-time feedback on the prevention of medication errors during e-prescription transactions between healthcare organizations. Aim 1 refines the design of a just- in-time feedback intervention, SAVE-Rx, and its implementation guide to identify unsafe e-prescription transactions. Aim 2 evaluates the implementation of the just-in-time feedback intervention for preventing unsafe e-prescription transactions. Our hypothesis is that we can improve the use of the intervention and alert performance by actively discontinuing alerts for safe mismatching pairs. Aim 3 determines the effects of the just-in-time feedback intervention on medication safety outcomes. Our hypothesis is that just-in-time feedback to healthcare organizations about unsafe e-prescription transactions will prevent clinically significant medication safety events. Accomplishing these aims will have a positive impact by testing a tool that is capable of actively monitoring and communicating useful feedback to healthcare organizations about unsafe e- prescription transactions on the more than 2 billion new e-prescription transmitted each year in the United States. At the end of this study, we expect to prevent at least 6,000 medication safety events as a result of implementing SAVE-Rx monitoring on 44 million e-prescription transactions.

项目摘要 虽然电子处方（e-prescriptions）在某些方面改善了患者的安全性，但它们 引入了新的错误类型，每年可能对患者造成高达439万次的重大伤害。 在电子处方处理过程中，当医生开出的药物是 与药剂师分发的药物相比，不同的成分、强度或剂型。主要 这些不安全的电子处方交易存在的原因包括不匹配的自由文本药物描述， 国家药物代码（NDC）和处方医生使用的计算机软件中的错误产品选择， 药剂师这些不安全的电子处方交易正在导致危险的用药错误， 导致严重患者伤害。为了系统地识别不安全的电子处方交易，我们 开发了一个名为SAVE-Rx的系统，该系统使用电子处方交易数据自动识别病例 在所规定的NDC与自由文本药物描述（即，电子处方错误）或 药房分发的药物的NDC。我们的系统将NDC和自由文本药物 使用标准化药物对药物成分、强度和剂型进行描述 国家医学图书馆RxNorm中的术语。然后审查不安全的电子处方交易 并通过现有的电子处方及时传达给医疗保健组织 在对患者造成伤害之前，我们的长期目标是通过以下方式提高药物安全性： 在药物处方和配药工作流程中战略性地使用自动化。的总体目标 本研究旨在探讨实施即时回馈对预防用药行为的影响 医疗机构之间的电子处方交易中的错误。目标1完善了公正的设计- 及时反馈干预SAVE-Rx及其识别不安全电子处方实施指南 交易目标2评价及时反馈干预的实施情况， 不安全的电子处方交易。我们的假设是，我们可以提高使用的干预和警报 通过主动停止安全不匹配对的警报来提高性能。目标3确定了 及时反馈药物安全性结果的干预。我们的假设是及时反馈 向医疗保健组织通报不安全的电子处方交易， 药物安全事件。实现这些目标将产生积极的影响，通过测试一个工具， 积极监测并向医疗机构传达有关不安全电子邮件的有用反馈， 美国每年传输超过20亿张新的电子处方， States.在这项研究结束时，我们预计将防止至少6,000起药物安全事件， 对4400万次电子处方交易实施SAVE-Rx监控。