Novel Use of a NON-Interactive Gold Form
Pediatric MinMax Dose Checking
Clinical INVISION CPOE - Session 9 15 August 2007 11:00-12:00
Who is this guy anyway?
W. Reid White, MSN, RN Clinical Lead Pediatric CPOE Application Systems Analyst Programmer II UNC Hospitals Information Services Division
All speakers have completed commercial bias disclosure forms and do not have any conflicts of interest.
Just what has UNC Hospitals done with CPOE?
UNC Hospitals & CPOE
• University teaching hospitals
Tertiary Care Center 708 licensed beds > 5000 Order Sets eChart live in NCCH for 136 beds (Soarian)
23 October 2002 13 January 2003 Medicine Acute Family Medicine 8BT pilot 3WST, 6BT, remainder of inpatient Medicine (except Oncology, Heart, CCU, and ICU) 3NSH, 4NSH, 5NSH, 5EDU Ramp down for all Medicine except MDB CDU, 5AD, 6EST, 3AD, MPCU, ICCU, & CCU REHB 4ADN, 5EST, 5WST, 5BT, 4ADS, STPU, ISCU, & PACU 6NSH CATH MICU SICU, NSICU & CTICU L&D, 5W, 6W (including GYN ONC except for Chemo Protocols) 8BT, 3WST, 6BT & MPCU BMTU 3AD, ICCU, 4ADS, TICU, CCU, MICU, CDU, SICU, NSIU & ISCU BMTU, 6EST, 5AD, 4ADN, 5BT, 5EST, 5WST, 6NSH, STPU, 6WH, 5WH, & L&D NCCC, NBN, PICU, CICC, 5CH, 6CH, & 7CH BURN, BICU PRU EACU, EPED, EMT, EURG GIP, OR, GCRC, Hemodialysis
23 September 2003 14 October 2003 06 April 2004
Medicine (re-live) and Cardiology Otolaryngology and PM&R Surgery and Orthopedics Neurology Cardiac Cath Lab Medicine ICUs Surgery ICUs OB/GYN Medical/Surgical Adult Units Oncology (MDE and MDT) Medical/Surgical Adult Units Medical/Surgical Adult Units
04 May 2004 25 May 2004 08 June 2004 21 September 2004 11 January 2005 18 January 2005 08 March 2005 21 September 2005 08 November 2005 06 December 2005 10 January 2006
09 May 2006 12 September 2006 03 April 2007 (sched) October 2007 TBD TBD TBD
North Carolina Children's Hospital (NCCH) Burn Procedure Recovery Unit Oncology Chemo Regimens Emergency Medicine Procedural Areas Outpatient Clinics
So, he’s going to talk about?
PEDIATRIC MINMAX DOSE CHECKING Pediatric definition from NC Children‟s Hospital subset of Pediatric is Neonatal mandated application of definitions pathway initiation logic MinMax a whole different beastie from adult consider data from children‟s Tylenol
Information from this presentation will assist you to: Identify patient safety considerations affecting design and integration of custom MinMax Dose Checking schemata Analyze Computerized Provider Order Entry pathways for potential loci of weakness which result from introduction of customized MinMax Dose Checking schemata Develop systems and clinical strategies for implementation of custom MinMax Dose Checking with Computerized Provider Order Entry systems
STATEMENT OF WORK
SERVICES REQUESTED Provide customized Pediatric MinMax dose checking for top 500 drugs identified by PED Clinical Pharmacists dynamic age ranges variable MinMax dose determination multiple dosing methodologies
KIDS – KEEP „EM SAFE! Drivers UNC Hospitals, Division of Pharmacy Services UNC School of Medicine, Department of Pediatrics Medication Errors Susceptible Population Data model for proposed MinMax solution “Pediatric Dosage Handbook, 13th edition”
ANALYZE clinical considerations OAS considerations BUILD EVALUATE & REVISE LEARN POST GO-LIVE SUMMARIZE
ANALYSIS Clinical considerations dynamic age ranges variable MinMax dose determination multiple dosing methodologies patient safety
ANALYSIS Clinical considerations dynamic age ranges multiple (one to seven) age ranges defined ranges vary per drug
ANALYSIS Clinical considerations variable MinMax dose determination dose dose / body metric dose / kg dose / m2
ANALYSIS Clinical considerations multiple dosing methodologies simple dosing dose (/ body metric) by indication mixed dosing (under development) dose / body metric / age dose / age dose / m2 / age dose / kg / age dose / body metric / age variable by route (IM vs IV)
ANALYSIS Clinical considerations patient safety differences in practice for tertiary care institution increased severity of illness special populations MinMax check first line of defense against error clinical checking remains in place
ANALYSIS OAS considerations patient safety issues profile data structure logic structure split process
ANALYSIS OAS considerations patient safety issues pathway insertion med order processing (custom) pediatric calculators (custom) neonatal MinMax checking (Siemens) adult MinMax checking pathway integration ability to loop back / revise (custom) pediatric calculators
ANALYSIS OAS considerations profile data structure three separate profiles dose units / dose dose units / body metric dose units / body metric by indication data entry screens simplify to minimize transcription error
ANALYSIS OAS considerations logic structure limitations of TCL-driven approach 35 for match in each MinMax check type >150 for all checks in each MinMax type more difficult to visualize structure and interplay
ANALYSIS OAS considerations split process perform dose check & generate error codes display errors (MinMax warning)
ANALYSIS OAS considerations logic structure developed from gestalt view / unified processing heavy use of “%GECNGHX” fields comment identify data manipulation U-fields 3-fields
BUILD age matching dose frequency MinMax check types
BUILD age matching age groups within the NC Children‟s Hospital extreme variation in age ranges per medication C0621 & C0622 multiple definitions per age range serial (up to seven) dynamic age ranges per MinMax check logic repeated through seven controllers
BUILD dose frequency calculation issues with text frequencies loop to strip off text data integer to convert to number model on “Pediatric Dosing Handbook” convert all frequenciew to # times / day
BUILD MinMax checking types dose unit / dose dose unit / body metric indication driven
BUILD MinMax checking types dose unit / dose profile error (predefined message) dose units error route error absolute max dose error one-time min dose error one-time max dose error age-related min dose error age-related max dose error age-related 24hr min dose error age-related 24hr max dose error
BUILD MinMax checking types dose unit / body metric profile error (predefined message) dose units error route error absolute max dose error one-time min dose error one-time max dose error age-related min dose error age-related max dose error age-related 24hr relative min dose error age-related 24hr relative max dose error age-related 24hr actual max dose error
BUILD MinMax checking types indication driven same MinMax check data as dose / body metric additional requirements to have user select indication match med to profile generate indication selection match med + indication to MinMax data
EVALUATION & REVISION
EVALUATION & REVISION %GECNGHX commenting paid off! tedious revision process for initial build Gestalt + Team paid off! translation of prior build for next prong minor revisions
POST GO-LIVE LESSONS
POST GO-LIVE LESSONS NO issues with pathway at go-live! few data issues discovered during the months after easy repair / revision BIG picture thinking & TEAMWORK paid off! design involved a dozen people gestalt view vastly simplified subsequent prongs Be careful what you wish for clinically inappropriate MinMax warnings 10% fuzzy logic
SUMMARY It‟s all about patient safety Thinking ahead of the game plan pays off OAS Gold‟s power and flexibility are incredible
DESIGN – Xxx
DESIGN – Xxx
DESIGN – Xxx
Thank you for you time and attention!
W. Reid White, MSN, RN
Application Systems Analyst Programmer II UNC Hospitals Information Services Division 321 Meadowmont Circle Chapel Hill, NC 27517-7583 919.966.4374 or pager 919.347.1068 fax 919.966.2110
May all your trails be crooked, winding, lonesome, dangerous leading to the most amazing view... where something strange, more beautiful and more full of wonder than your deepest dreams awaits. Edward Abbey
In accordance with UNC Hospitals policy the opinion(s) expressed in this document do not necessarily represent the opinion(s) of UNC Hospitals or its management.
Thank you for attending this session. Session 9 Novel Use of Non-interactive Gold Form: Min/Max Dose Checking
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