Prescribing Safety Alerts

1
Prescribing Safety Alerts
Pray keep the noise down, theres a good chap!
Geez peace!

• Dr Ian McNicoll
• Clinical Analyst - SCIMP, Ocean Informatics
• Dr Brian McKinstry
• Dept of General Practice, University of Edinburgh
  and CSO Fellow

2

• Importance of prescribing safety
• Background to SEF
• Implementation of SEF
• Lessons learned
• Current challenges in medication related clinical
  decision support
• Future developments

3
Why Prescribing Safety

• Medication related adverse events are a major
  cause of death and injury.
• It has been estimated that around 6.2 of
  hospital admissions and 5700 deaths per year in
  the UK are due to adverse drug events.
• Systematic reviews in the area have confirmed the
  central role that information technology has in
  the reduction of prescribing errors

4
(No Transcript)
5
Patient Safety Agency Study

• Two round Delphi approach to reach agreement on
  the most important safety features of general
  practice computer systems
• Panel judged 32 of these statements to be
  important, and these were then used to develop
  scenarios
• Drug-condition, drug-drug, drug-age, drug-lab
  result

6
Prescribing scenarios tested

• Aspirin prescribed for a child of eight years 
• Methotrexate prescribed in pregnancy 
• Penicillin prescribed in a patient with
  penicillin allergy 
• Oxytetracycline prescribed in with renal
  impairment 
• Enalapril prescribed in patient with renal
  impairment
• Microgynon 30 (a combined oral contraceptive
  pill) prescribed in a patient with a past history
  of DVT
• Oxytetracycline prescribed in a patient with a
  serum creatinine of 160 mmol/l 
• Propranolol prescribed in a patient with CCF 

7
Results

• None of the systems met all the criteria.
• They varied in the warnings they gave
• All suppliers felt the problems could be
  rectified
• How could this be encouraged

8
The solutionScottish Enhanced Functionality

• Speak softly but carry a big stick
• (Theodore Roosevelt)

• Minimum standards for prescribing safety
• No SEF revalidation means No reimbursement for
  GP system
• No extra funding to vendors to help with SEF
  costs
• Must be used judiciously

9
SEF Prescribing Safety 2006

• Based on NPSA paper aimed to include
• Drug-drug interaction alerts
• Allergy warnings
• Contraindication warnings due to pregnancy
• Drug-disease contra-indication alerts
• Inappropriate dosage warnings
• Duplicate therapy warnings
• Similarly named drug alerts.
• Awareness that many systems already had
  implemented these warnings

10
SEF Prescribing Safety

• A minimum of one click would be required to
  over-ride every type of alert.
• Where potentially more serious alerts are raised,
  the supplier should ensure that it is not
  possible to continue prescribing without
  requiring the clinician to verify they wish to
  override by a second prompt
• The underlying reason for each alert had to be
  highly accessible.
• The supplier should ensure that ALL alert
  overrides are registered on the system for
  medico-legal purposes.

11
SEF Prescribing Safety

• Complete block
• Methotrexate less than weekly
• Similar drug name warning
• Penicillamine lt-gt Penicillin
• High level alerts
• 2 action override No blanket override
• Allergies
• Level 3-4 drug-drug interactions

12
SEF Prescribing Safety Overrides

• For the lower levels of alert (e.g. Multilex
  Grades 1 and 2 equivalent), overrides might be on
  an individual alert basis or through the end-user
  switching off this level of alert in the system.
• For more serious alerts (e.g. Multilex grade 3
  and 4 equivalents), the supplier should ensure
  that it is not possible for the end user to
  switch off the alert system.
• If the user has switched off these lower levels
  of alert the suppliers must still ensure that the
  system records the fact that the alert system was
  switched off when the prescription was issued.

13
SEF Prescribing Safety - Development

• Testing
• Test scripts testing by commercial 3rd party
• Minimum standards
• User Group sign off
• Vendor Beta testing
• Few grumbles about over-alerting but...

14
(No Transcript)
15
June 2008 SEF Rollout

• Unacceptable levels of over-alerting
• Drug doubling alerts
• Drug condition checking
• Clumsy double-click override mechanism

16
SEF Response

• Immediate dialogue with User Group reps via SCIMP
• Immediate discussion with vendors inc. drug
  safety database suppliers
• Sample SEF override logs from users

17
Contraindications for CERAZETTE Undiagnosed
gynaecological bleeding READ Trigger Menorrhagia

Precautions for DIAZEPAM Cardiorespiratory
insufficiency, Renal impairment. Reduce Dose
Contraindications for DIAZEPAM Porphyria READ
Trigger Gout
Prescriber Warnings for DIAZEPAM Monitor
patients with marked personality
disorder (trigger anxiety)
18
Diagnosis

• Misunderstandings about Blanket overrides
• Some vendors did not allow overrides on lower
  alert levels (not SEF requirement)
• Condition checking / Drug doubling
• Issues around age-related alerts
• Aimed at children
• Many non-specific alerts in elderly
• Condition checking misfiring in some systems
• Over-inclusive matching
• BPH Erectile dysfunction
• Vendors not using most up to date versions

19
Lessons Learned

• The Supply Chain
• Involve ALL stakeholders early
• Use vendor, safety product provider expertise
• End to end testing important
• Standard Requirements documentation inadequate
• Agile, Collaborative approach w vendors

20
Formal Clinical Safety review

• Standard Beta testing insufficient
• Standard script led testing insufficient
• Experienced informaticians/users
• Hands-on evaluation
• Time and funding
• GP2GP Clinical Safety testing

21
Positives?

• First attempt to define national prescribing
  safety standards?
• Most of the recommendations were reasonable
• Override logs will prove a valuable research
  resource to improve alert accuracy
• Highlighted the issues, state of the art
  prescribing safety.
• Excellent cooperation from all involved