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Citation Type of Study
Framework/Theory Setting Key Concepts/Variables Findings Hierarchy of Evidence Level
Abraham, J., Kannampallil, T. G., Jarman, A., Sharma, S., Rash, C., Schiff, G., & Galanter, W. (2018). Reasons for computerized provider order entry (CPOE)-based inpatient medication ordering errors: An observational study of voided orders. BMJ Quality & Safety, 27(4), 299-307. doi:10.1136/bmjqs-2017-006606 Qualitative study; observational design, clinical interviews, and patient chart reviews; a structured coding framework A Midwestern academic center, United States;
495-bed hospital A Void Alert Tool to identify inpatient voided orders; reasons for medication ordering errors Timely follow-up on ordering errors with computerized provider order entry is beneficial for patient safety and avoidance of violations (Abraham et al., 2017) III
Amiri, P., Rahimi, B., & Khalkhali, H. R. (2018). Determinant of successful implementation of computerized provider order entry (CPOE) system from physicians’ perspective: Feasibility study before implementation. Electronic Physician, 10(1), 6201-6207. doi:10.19082/6201 Quantitative study; a cross-sectional design; a questionnaire; the Diffusion of Innovation Theory Two hundred physicians from the hospitals in Urmia University of Medical Sciences (from March 2017 to June 2017) IV: CPOE; DV: physicians’ attitudes toward the system The CPOE system is characterized by relative advantages, including medication error reduction and high-level patient safety (Amiri et al., 2018) II
Khammarnia, M., Sharifian, R., Zand, F., Barati, O., Keshtkaran, A., Sabetian, G., Shahrokh, G., & Setoodezadeh, F. (2017). The impact of computerized physician order entry on prescription orders: A quasi-experimental study in Iran. Medical Journal of the Islamic Republic of Iran, 31. doi:10.14196/mjiri.31.69 Quantitative study; a quasi-experimental design; a before-after prospective study Two intensive care unit (ICU) wards with 14 beds of a tertiary academic medical centre in Shiraz, Iran (from 2014 to 2016) IV: CPOE; DV: prescription errors in ICUs The application of CPOE reduced the number of prescription errors and led to the improvement of care quality in hospital services (Khammarnia et al., 2017) III
Lyons, A. M., Sward, K. A., Deshmukh, V. G., Pett, M. A., Donaldson, G. W., & Turnbull, J. (2017). Impact of computerized provider order entry (CPOE) on length of stay and mortality. Journal of the American Medical Informatics Association, 24(2), 303-309. doi:10.1093/Jamia/ocw091 Quantitative study; retrospective, pre-post design; an antecedent structure process framework The University of Utah Health Sciences Center; 66,188 unique patients and 104,153 admissions IV: CPOE; DV: inpatient mortality and length of stay CPOE was proved a statistically significant predictor of patient mortality and the length of stay (Lyons et al., 2017). III
Rabiei, R., Moghaddasi, H., Asadi, F., & Heydari, M. (2018). Evaluation of computerized provider order entry systems: Assessing the usability of systems for an electronic prescription. Electronic Physician, 10(8), 7196-7204. doi:10.19082/7196 Quantitative study; an evaluation design Five public hospitals in Tehran, Iran, and 254 nurses who work there IV: CPOE;
DV: usability, friendliness, decision support, prescription support, and patient safety Regarding evident friendliness and usability of the system, CPOE has to be developed in prescription and decision-making to improve patient safety (Rabiei et al., 2018) III
The application of a computerized provider order entry (CPOE) is frequently discussed in many healthcare facilities around the globe. In the majority of cases, researchers focus on the impact of this system on such factors as patient safety, care quality, and medication error avoidance (Abraham et al., 2017; Amiri et al., 2018; Khammarnia et al., 2017; Lyons et al., 2017; Rabiei et al., 2018). According to Abraham et al. (2017), some acute care hospitals are challenged by multiple medication ordering errors, and it is expected to develop a system in terms of medication voiding. The elimination of handwritten paper orders could promote cost savings and increase hospital efficiency (Khammarnia et al., 2017). Therefore, the chosen PICO question about the necessity to compare paper-based methods and e-prescription can be adequately answered, using examples from different parts of the world.
In addition to the expected organizational and financial benefits and medication error control, CPOE is characterized by a number of positive reactions from nurses and physicians. Although there are many medical centers and clinics where CPOE is poorly studied, the staff shows high friendliness and usability intention (Rabiei et al., 2018). Amiri et al. (2018) thoroughly studied the physicians’ perspective. Hospitals are interested in implementing the electronic system because it helps reduce medication errors, prevent adverse drug events, and improve the quality of care. The advantages of CPOE are also determined by patients and services the influence their admissions. Lyons et al. (2017) prove that there is a connection between the length of stay, mortality, and CPOE. Still, additional studies are required to analyze the system through the prism of individual patient care units, room levels, and the hospital system (Lyons et al., 2017). Regarding the conclusions about the effectiveness of the CPOE system, the offered PICO question turns out to be a reasonable contribution because it positively influences the quality of care, raises interest among nurses and physicians and reduces medical errors in acute care.
The main idea of this study is to compare the effects of CPOE systems with e-prescriptions and paper methods within an acute care unit where patients with chronic pain receive their treatments. In fact, it is necessary to explain the characteristics of two independent variables (CPOE and the paper-based system) and define their impact on one dependent variable (medication errors). Regarding the nature of the task, it is expected to develop a quasi-experimental study. The researcher should choose a hospital or several medical centers, but this choice is not random because not all facilities may meet the inclusion criteria. One (experimental) group of nurses has to work with the CPOE system and e-prescriptions, and another (control) group of nurses needs to continue working with the paper-based system. The quasi-experimental nature of this case is a unique opportunity to remove differences between hospitals and patients and focus on the idea of acute care digitalization. This research will show how the CPOE system may be implemented, how the paper-based system works, what expectations the nurses of the chosen hospital(s) have, and what outcomes in terms of medication errors may be achieved.
During the development of this quasi-experiment, several sources of information should be addressed. First, it is important to create a solid background in order to understand what has already been known about CPOE and paper-based systems and which medication errors challenge hospitals. It is expected to use several credible databases like CINAHL, MEDLINE, and PubMed and choose at least five peer-reviewed articles published within the last five years. The next source of information about the currently implemented systems is the hospital itself. Informed consent must be signed, and the hospital’s administrators approve the researcher’s intervention. Then, it is necessary to identify where paper-based systems are applied and where the implementation of a CPOE system is possible (or has already been observed). Finally, nurses are the main sources of information for this study because of their reports about medication errors and the application of the system.
A questionnaire will be used to collect data before and after the intervention. The purpose of this method is to gather the required information about the chosen idea from direct participants. An approved number of nurses will receive a list of questions about the number of current medication errors, the preferred order system, and a pain type in patients. The same questionnaire has to be sent to a control group and an experimental group within a specific period of time (a week before the intervention and a week after the intervention). Nurses are able to share their opinion about the offered system and report the number of mistakes during the care process.
In general, the evaluation of the CPOE system has to be organized in the following way:
Who? Nurses who work with patients with chronic pain
What? The application of the CPOE and paper-based systems
When? One week before the intervention and one week after the intervention
Where? In acute care units of local hospitals
How? Nurses complete a questionnaire focused on medication errors in hospitals and developed before the intervention
Descriptive statistics are obtained from questionnaires in a quasi-experimental study. It is not enough to introduce the answers of the participants but to analyze the offered material in terms of the already identified dependent and independent variables. With the help of the SPSS software program, a researcher will conduct data analysis. The t-test will be effective for comparing quantitative data in the experimental and control groups (Rabiei et al., 2018). This method is necessary because there are two independent variables, and it is expected to find out which system is beneficial for acute care units. Another method to measure the success of the intervention is McNemar’s test, the purpose of which is to compare the number of medication errors separately in the experimental and control groups (Khammarnia et al., 2017). On the one hand, these data analysis methods will prove the possibility of decreasing medication errors within a particular setting. On the other hand, this analysis aims at comparing the two methods and understanding which one is a better option for acute care units.
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Finally, the summary of the evaluation will be presented in several forms. First, the results of McNemar’s test can be introduced in a table format to illustrate the differences between the systems. Then, the researcher will use the statistical findings and explain why the CPOE system should be implemented instead of the paper-based system in local hospitals. In this case, it is enough to create a text and describe the intervention and the findings. Nurses, as well as other healthcare providers, are interested in predicting medication errors; therefore, if no significant financial or organizational challenges are observed, the CPOE has to be proved as the only effective method.
The implementation of the CPOE system in healthcare facilities is a beneficial intervention to reduce the number of medication errors. Despite the already obtained technological progress and digitalization outcomes, many hospitals continue addressing handwritten paper orders that are not always easy to read and store (Amiri et al., 2018; Khammarnia et al., 2017). Besides, confidential issues are frequently identified and challenge the work of nurses, physicians, and pharmacists. Therefore, the implementation of a new initiative is a unique contribution to the promotion of patient safety and the improvement of care quality. The Agency for Healthcare Research and Quality (AHRQ, 2018) offers a number of tools to help hospitals and healthcare providers make care safer and understand the worth of research-based studies. Some initiatives are directed to providers and their possibilities to control and change the environment. Some instruments influence the whole system and facilities. If a process needs improvement, the representatives of the AHRQ are ready to offer their options.
In this study, the purpose is to compare the worth of one system with the effects of another system. It seems that the quality of care and the possibility to decrease the number of errors may be interpreted as the patient safety culture. Therefore, AHRQ’s Surveys on Patient Safety Culture (SOPS) may be considered as a tool to support survey users, develop their activities, and improve patient safety culture (AHRQ, 2018). According to SOPS, to evaluate the program, it is expected to answer ten questions, which are divided into four main categories (defining goals, planning an initiative, timeline, and action plan communication). Although a quasi-experiment is the method chosen for this study, its design is similar to those in surveys. The SOPS initiative shows how the staff perceives safety and what sources are crucial for the chosen intervention. As soon as the main questions are posed, and all the necessary comments are given, the participants could understand if the change is an optimal solution for a particular situation or not.
There are four main phases in the evaluation tool that is chosen for this study. The first task is to define the goals and select an initiative. According to the PICO, the area of improvement is care that is determined by medication prescriptions. Patients do not understand how the way of prescription could influence their condition, but nurses are properly aware of this process. Cooperation between nurses, doctors, and pharmacists depends on the speed and quality of data exchange. The project aims to decrease medication errors in an acute care unit where patients with chronic pain are treated. The initiative is to implement the CPOE system with e-prescriptions.
The second phase is based on planning an intervention, including the identification of participants (nurses), leaders (a researcher), resources (CPOE and paper-based systems), barriers (the lack of knowledge and experience), and measurement. The way of how the CPOE system is measured is integral in SOPS because it touches upon the outcome and process aspects. The establishment of a timeline cannot be ignored because the research and nurses should know their limits and complete their work within a certain period. The final stage of the chosen tool is the action plan communication. As soon as the goals and expected results are discussed, a research team and the hospital’s staff should clarify how it is possible to share the initiative and prove its appropriateness for an acute care unit. The benefit of this survey is not only to compare the differences between systems and the possibility of error elimination but the identification of the participants and their roles. In addition to descriptive statistics, this study helps improve human resource management and process management.
In general, SOPS is a solid evaluation tool for this evaluation project. The rationale for such a selection lies in the areas of improvement and the discussion of the role of all participants, both direct and indirect. Medication errors are frequent in healthcare practice, and many ideas are constantly developed as per available resources. Sometimes, nurses understand that their responsibility is to support cooperation, but their contributions are not enough to cover all the shortages of the working process. Therefore, SOPS covers a number of issues in healthcare practice, including people, processes, attitudes, and further perspectives. The reliability of this initiative is proved by the fact that it was developed by a credible organization, AHRQ. An action plan does not include complex steps and tasks, and nurses with different backgrounds are able to follow it and evaluate the intervention. In addition, during the evaluation process, it is possible to learn the barriers to implementing the system and understand how to overcome them. A quasi-experimental study and survey create an excellent opportunity to improve care, achieve the desired outcomes, and invite the required number of participants who take their specific responsibilities.
Abraham, J., Kannampallil, T. G., Jarman, A., Sharma, S., Rash, C., Schiff, G., & Galanter, W. (2018). Reasons for computerised provider order entry (CPOE)-based inpatient medication ordering errors: An observational study of voided orders. BMJ Quality & Safety, 27(4), 299-307.
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Agency for Healthcare Research and Quality. (2018). SOPS action planning tool. AHRQ. Web.
Amiri, P., Rahimi, B., & Khalkhali, H. R. (2018). Determinant of successful implementation of computerized provider order entry (CPOE) system from physicians’ perspective: Feasibility study prior to implementation. Electronic Physician, 10(1), 6201-6207.
Khammarnia, M., Sharifian, R., Zand, F., Barati, O., Keshtkaran, A., Sabetian, G., Shahrokh, G., & Setoodezadeh, F. (2017). The impact of computerized physician order entry on prescription orders: A quasi-experimental study in Iran. Medical Journal of the Islamic Republic of Iran, 31.
Lyons, A. M., Sward, K. A., Deshmukh, V. G., Pett, M. A., Donaldson, G. W., & Turnbull, J. (2017). Impact of computerized provider order entry (CPOE) on length of stay and mortality. Journal of the American Medical Informatics Association, 24(2), 303-309.
Rabiei, R., Moghaddasi, H., Asadi, F., & Heydari, M. (2018). Evaluation of computerized provider order entry systems: Assessing the usability of systems for electronic prescription. Electronic Physician, 10(8), 7196-7204.