Medication safety and knowledge-based functions: a stepwise approach against information overload

Abstract

Aims: The aim was to improve medication safety in an emergency department (ED) by enhancing the integration and presentation of safety information for drug therapy.

Methods: Based on an evaluation of safety of drug therapy issues in the ED and a review of computer-assisted intervention technologies we redesigned an electronic case sheet and implemented computer-assisted interventions into the routine work flow. We devised a four step system of alerts, and facilitated access to different levels of drug information. System use was analyzed over a period of 6 months. In addition, physicians answered a survey based on the technology acceptance model TAM2.

Results: The new application was implemented in an informal manner to avoid work flow disruption. Log files demonstrated that step I, 'valid indication' was utilized for 3% of the recorded drugs and step II 'tooltip for well-known drug risks' for 48% of the drugs. In the questionnaire, the computer-assisted interventions were rated better than previous paper based measures (checklists, posters) with regard to usefulness, support of work and information quality.

Conclusion: A stepwise assisting intervention received positive user acceptance. Some intervention steps have been seldom used, others quite often. We think that we were able to avoid over-alerting and work flow intrusion in a critical ED environment.

Keywords: computerized; decision support systems; electronic prescribing; medical records system; medication safety; medication therapy management; technology acceptance model.

Figure 1

The new Orbis electronic case sheet is based on the 4SDRI principle . Seven drugs have been entered. Step I: Tick boxes indicating whether or not the current indication of the drug is known. Step II: A tooltip information appears for drugs previously associated with problems in the ED. Step III: ‘MedikationsCheck’ button invokes CDSS (OntoDrug®) and transfers patient drugs, diagnoses, age, gender and creatinine value. New pop-up window displays contraindications, warnings and interactions, here metformin is contraindicated with diagnosis of chronic renal insufficiency. Step IV: warning extract is linked to SPC in Pharmindex Plus® and activated by clicking on highlighted link. The risk situation found in step III is immediately highlighted. Targeted drug information is displayed

Figure 2

Frequencies of cases and electronic case sheets plus means of usage of four steps approach per calendar week. , cases; , electronic case sheets; , electronic case sheets with ≥drug; , drugs/electronic case sheet (mean); , indications confirmed/drug (mean); , tooltips/drug (mean)

Figure 3

Frequency of medication safety measure usage in daily routine, n = 9 emergency physicians. , no answer; , use several times per day; , use once a day; , use weekly; , use monthly; , don't use at all

Figure 4

The 4SDRI model and the five rights principle by Sirajuddin et al. [22]