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From Clinfowiki
Overhage, John M., Tierney, William, M., Zhou, Xiao-Hua (Andrew), McDonald, Clement J. A Randomized Trial of “Corollary Orders” to Prevent Errors of Omission. Journal of the American Medical Informatics Association. 1997 September/October; 4 (5): 364 – 375.
Summary:
Errors of omission are surprisingly common in the modern practice of medicine. Physicians, despite their knowledge, often overlook new clinical abnormalities or fail to give adequate consideration to preventive care. This article reviewed the theory that automated reminders based on clinical guidelines and directed at prescribers during order entry might be an effective means of reducing the frequency of these types of errors.
In this particular study, computerized suggestions to clinicians to include corollary orders had a major impact on the adherence to clinical guidelines, effectively reducing errors of omission. Previous studies involved the use of computer workstations to discourage the entry of orders for unnecessary tests and treatments, which led to substantial cost reductions and outcome improvements.
As part of this study, the authors outlined four mechanisms for redesigning health care systems to significantly reduce the chance of error: (1) reduce reliance on memory; (2) improve access to relevant clinical information; (3) standardize treatments whenever possible; and (4) thoroughly train users on system features.
[Methods:] Data for this study were collected on the inpatient general medicine unit of an inner-city public teaching hospital. Patients are followed and cared for by one of six different services, with different levels of clinical experience represented on each team. Patients were admitted to each service in sequence so all six services received equal numbers of admissions over time. On average, each team cared for an average of 16 patients at one time. All physicians on each team had been entering inpatient orders directly into physician workstations for a minimum of 12 months, and 75% of inpatient orders were written from sites other than the patient’s clinical unit. And less than 5% of the orders are entered by nursing staff as verbal orders from physicians.
A number of outcome variables were reviewed. The main area of expected change was the per physician compliance with automated ordering guidelines, and responses were categorized as “immediate compliance”, “24 hour compliance”, and “hospital stay compliance”.
Results:
The use of computers to remind physicians about associated orders as they write orders that trigger additional suggested orders can be implemented effectively without incurring significant ongoing costs, if physicians were already writing orders by using computer workstations. One estimate from another similar study suggested that computer interventions during order-entry could have the potential to reduce adverse effects by 25 – 49%, leading many hospitals to fast-track implementation. Further, presentation of fully-configured order suggestions made this approach more competitive from a time perspective when compared to the previous paper-based system. Systems can be configured to present information to physicians in a w ay that allows them to proceed without stopping to think about ordering follow-up tests, or enter instructions about an order. They have the option of quickly scanning the order, and accepting the order with a single keystroke or mouse click.
Kevin Connett
