Reducing Medication Errors by Improving an Electronic Medical Record's Automatic Stop Medication Order Process

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Advisor: James Pelegano, Thomas Jefferson University, Philadelphia, PA.


After missing 5 days of prednisone during a lengthy hospitalization, a patient developed adrenal insufficiency requiring ICU level care. The medication had been inadvertently discontinued according to the hospital’s automatic stop medication order (ASO) policy. This was deemed a serious preventable harm event. A root cause analysis identified multiple failure modes involving the prescriber, the pharmacist and the nurse. These failures did not reflect the fault of a given individual but rather significant challenges in an inefficient process. A process improvement team gathered to create a patient safety action plan. They utilized a physician survey to uncover that the current 11-click renewal process is poorly understood and minimally adhered to by clinicians with 87% of respondents calling for improvement in the process. The safety net process of pharmacy calls to prescribers for clarification regarding renewal of expiring medications had become the de facto first line of defense against inadvertent medication discontinuation. A staggering 5,000 phone calls were made to prescribers monthly with a 65% renewal rate. This translated to more than 700 near misses for inadvertent discontinuation of medications each month. The team undertook a complete overhaul of the current ASO policy leading to lengthening of the default duration of most medications in its formulary. Chronic medications moved from a 30 day default to 90 days. IT enhancements include colored and more intuitive icons indicating an order is approaching expiration (OAE), nurse “view only” capacity of OAE’s and development of a single click process to renew a medication or allow it to expire.

Presentation: 49 minutes

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