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Information technology to improve patient safety: A round table discussion from the 5th International Patient Safety Forum, Riyadh, Saudi Arabia, April 14–16, 2015 Yaseen M. Arabi, Brian W. Pickering1, Hasan M. Al-Dorzi, Abdulmohsen Alsaawi, Saad M. Al-Qahtani, Alasdair W. Hay

A simple definition of patient safety is the prevention of error or harm associated with healthcare. An up‑to‑date definition is more holistic. Patient safety has expanded to include providing high‑quality care.[1] The goals of patient safety have similarly expanded to include delivering evidence‑based care in a timely manner rather than just eliminating errors.

Information technology (IT) has wide‑ranging spectrum applications in patient safety in the acute care setting and, in particular, the Intensive Care Unit (ICU) setting. Throughout this paper, we provide a summary of the discussion from the roundtable meeting from the 5th International Patient Safety Forum, held in Riyadh, Saudi Arabia on April 14–16, 2015 that covered several aspects of how IT can improve patient safety, with a focus on the ICU setting. The format of the roundtable included presentations and general discussions. The potential risks associated with novel IT methods and technologies were also discussed. The meeting provided evidence by showcasing specific successful IT projects.

Healthcare, particularly ICU care, is complex and involves multiple processes. Defect rates are estimated to be in the order of 1/10 to 1/1000, making healthcare frequently unreliable.[1] Arguably the most important goal of modern healthcare is standardization and improvement in reliability. Standardization means the provision of the same good medical care to all patients. It involves the implementation of evidence‑based clinical practice guidelines. IT can help standardize a complex healthcare. Table 1 describes steps for standardization of care using health IT.

Computerized physician order entry (CPOE) systems are already transforming healthcare. T h e s e s y s t e m s a r e w i d e l y u s e d a n d a r e recommended by the Institute of Medicine[2]

to improve patient safety and reduce errors. CPOE is the use of an institutional computerized health record to electronically enter orders. The technology often includes prompts, alerts, dose calculators and interfacing with laboratory and radiology test results. The value of CPOE lies in optimizing order communication, providing real‑time decision support, and facilitating standardization of care [Table 2].

The completion of a single medication dose requires executing many steps.[3] Errors can happen at any of these steps. An ICU study found that the most common error types were wrong dose (11.7%), wrong administration time (13.9%), dose omission (14.4%), and wrong administration rate (40.1%) with the commonly involved medications being antibiotics, electrolytes, cardiovascular drugs and sedatives/analgesics.[4] A prospective study compared a paper‑based ICU and a CPOE‑ICU. The study found that the CPOE‑ICU had a lower incidence of medication prescription errors (3.4% vs. 27.0%) and adverse drug events (2 vs. 12).[5] A recent systematic review estimated that processing a prescription drug order through a CPOE system decreases the

Address for correspondence:

Dr. Yaseen M. Arabi, Intensive Care

Department, College of Medicine, King Saud bin Abdulaziz University for

Health Sciences, King Abdullah International

Medical Research Center, King Abdulaziz Medical

City, P.O. Box 22490, Riyadh 11426,

Kingdom of Saudi Arabia. E-mail: arabi@ngha.med.sa

Submission: 26-07-2015 Accepted: 26-10-2015

King Saud bin Abdulaziz University for Health

Sciences, King Abdullah International Medical

Research Center, Riyadh, Kingdom

of Saudi Arabia, 1Department of

Anesthesiology, Division of Critical Care Medicine,

Mayo Clinic, Rochester, Minnesota, USA

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DOI: 10.4103/1817-1737.176877

How to cite this article: Arabi YM, Pickering BW, Al‑Dorzi HM, Alsaawi A, Al‑Qahtani SM, Hay AW. Information technology to improve patient safety: A round table discussion from the 5th International Patient Safety Forum, Riyadh, Saudi Arabia, April 14–16, 2015. Ann Thorac Med 2016;11:219‑23.

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Arabi, et al.: Information technology and patient safety

220 Annals of Thoracic Medicine – Vol 11, Issue 3, July-September 2016

likelihood of error on that order by nearly 50%. It was projected that >100,000,000 medication errors could be averted if CPOE was adopted in all US hospitals.[6]

Incorporating decision support systems into CPOE has also been shown to be beneficial. A before‑after CPOE‑ICU study, with an integrated clinical decision support system, showed a decrease in the erroneous prescription of medications to which patients had reported allergy from 146 to 35 (P < 0.01), a decrease in antibiotic‑susceptibility mismatches from 206 to 12 (P < 0.01), reductions in the number of days of excessive drug dosage (2.7 vs. 5.9 days, P < 0.001) and a decrease in

adverse drug events from 28 to 4 (P < 0.01). Another before‑after study found that an evidence‑based computerized decision algorithm for red blood cell transfusion in an adult ICU was associated with a decrease in the number of transfusions per ICU admission from 1.08 units before to 0.86 units after the protocol (P < 0.001), in the rate of inappropriate transfusions (17.7% vs. 4.5%, P < 0.001) and in the rate of transfusion complications (6.1% vs. 2.7%, P = 0.015).[7] There are many other examples of CPOE facilitating protocol implementation and thus improving patient outcomes. Examples include the management of hyperglycemia,[8] acute myocardial infarction[9] and chemotherapy regimens.[10] A before‑after study conducted in the ICU at King Abdulaziz Medical City, Riyadh (KAMC‑R), Saudi Arabia found that CPOE implementation was associated with no change in ICU and hospital mortality in the immediate period and up to 12 months after implementation.[11]

However, the introduction of CPOE systems can introduce substantial vulnerabilities. Any change in medical care can be accompanied with unintended consequences.[12] A study at a tertiary‑care hospital found that a new CPOE system facilitated 22 types of medication error risks, as a result of fragmented CPOE displays, false interpretation of dosing guidelines, inflexible ordering formats, delayed ordering due to system unavailability and other factors.[13] CPOE may also change workflow such that CPOE becomes time consuming leading to less time spent with the patients. Moreover, it may increase the clinician’s reliance on IT instead of face‑to‑face verbal communication with other healthcare providers for planning and coordinating their work. Hence, CPOE system implementation should be well planned and should involve all stakeholders. Potential vulnerabilities should be considered and addressed before the Go‑Live. The system performance should be audited and continuously enhanced according to the specific hospital’s needs. The effect of CPOE on various stakeholders, such as physicians and nurses, its impact on patient safety and other patient outcomes and its cost‑effectiveness should be studied in randomized controlled trials.

A basic CPOE system allows physicians to improve care by reducing errors and standardizing treatment from the time of initial diagnosis or recognition of a clinical problem. However, compliance with the best practices also requires clinicians to reliably identify patients requiring specific treatment early and respond quickly to new clinical problems. Modern technology means that more of the information required to deliver timely care is available, but this information needs to be delivered to physicians to help them act quickly and reliably. Electronic alert systems can be adapted to aid in the diagnostic process. For example, in a large randomized controlled trial, with over 2500 patients, patients were randomized to either an intervention group, with the physician receiving a computer alert of the patient’s venous thromboembolism risk or to a control group with no alert. There was a clinically and statistically significant improvement in care in the intervention group: Mechanical prophylaxis (10.0% vs. 1.5%) and pharmacologic prophylaxis (23.6% vs. 13.0%).[14] Two successful IT projects from KAMC‑R, where alert systems have been used to improve clinical care, were presented at the 5th International Patient Safety Forum. These were the automation of the

Table 1: Steps to perform standardize care using health information technology Identify a high-priority clinical process Identify a champion for implementation of change Obtain senior leader support Build an evidence-based or best practice protocol Involve all stakeholders in developing process change and the protocol for successful buy-in Blend the protocol into clinical workflow (clinical decision support; default choice that happens automatically unless someone must modify) Allow clinicians to vary based on patient needs. This will also help buy-in and increase compliance Embed data systems to track