Orwik

Catheter duration and risk of CLA-BSI in neonates with PICCs.

OBJECTIVE: To determine whether the risk of central line-associated bloodstream infections (CLA-BSIs) remained constant over the duration of peripherally inserted central venous catheters (PICCs) in high-risk neonates. PATIENT AND METHODS: We perform... expand abstracted a retrospective cohort study of NICU patients who had a PICC inserted between January 1, 2006, and December 31, 2008. A Poisson regression model with linear spline terms to model time since PICC insertion was used to evaluate potential changes in the risk of CLA-BSI while adjusting for other variables. RESULTS: Six hundred eighty-three neonates were eligible for analysis. There were 21 CLA-BSIs within a follow-up period of 10 470 catheter-days. The incidence of PICC-associated CLA-BSI was 2.01 per 1 000 catheter-days (95% confidence interval [CI]: 1.24-3.06). The incidence rate of CLA-BSIs increased by 14% per day during the first 18 days after PICC insertion (incidence rate ratio [IRR]: 1.14 [95% CI: 1.04-1.25]). From days 19 through 35 after PICC insertion, the trend reversed (IRR: 0.8 [95% CI: 0.66-0.96]). From days 36 through 60 after PICC insertion, the incidence rate of CLA-BSI again increased by 33% per day (IRR: 1.33 [95% CI: 1.12-1.57]). There was no statistically significant association between the risk of CLA-BSI and gestational age groups, birth weight groups, or chronological age groups. CONCLUSIONS: Our data suggest that catheter duration is an important risk factor for PICC-associated CLA-BSI in the NICU. A significant daily increase in the risk of CLA-BSI after 35 days may warrant PICC replacement if intravascular access is necessary beyond that period. collapse abstract

Neonatal brain imaging and the identification of metabolic acidemia and hypoxic-ischemic encephalopathy.

OBJECTIVE: To determine the precision with which intrapartum metabolic acidemia and hypoxic-ischemic encephalopathy (HIE) in term and near-term infants can be identified by neonatal brain imaging. STUDY DESIGN: This is a case-control study whose incl... expand abstractusion criteria were neonates born at > or =34 weeks gestation with a cord gas at delivery, suspected neurological abnormalities, and computed tomography (CT) or magnetic resonance (MR) imaging of the brain. Neonates with chromosomal and major congenital malformations were excluded. Brain imaging for neonates with and without metabolic acidemia (pH < 7.0 and base deficit > 12 mM) at birth and HIE were retrospectively reviewed by a neuroradiologist blinded to their clinical course and compared. RESULTS: There were 54 neonates admitted to the NICU at a single university hospital between 1992 and 2006 that met these inclusion criteria of which 27 had metabolic acidemia at birth. There were 16 diagnosed clinically as having HIE at the time of neonatal discharge, 13 from the acidemic group and 3 from the nonacidemic group. Radiological signs of basal ganglia injury were significantly more common in neonates with metabolic acidemia (29.6%, 3.7%, p = 0.02) and HIE (37.5%, 7.9%, p = 0.01). Logistic regression corrected for gestational age showed that radiological signs of basal ganglia injury could identify the presence of HIE with area under the ROC curve of 0.71, sensitivity 37.5%, specificity 92.1%, positive predictive value 66.7%, and negative predictive value of 77.8%. CONCLUSION: Radiological signs of basal ganglia injury on early neonatal imaging are associated with metabolic acidemia and HIE, but is not precise enough to serve as a gold standard in the identification of these conditions. collapse abstract

Assessing controlled substance prescribing errors in a pediatric teaching hospital: an analysis of the safety of analgesic prescription practice in the transition from the hospital to home.

Iatrogenic errors producing serious and often preventable injury occur frequently in hospitalized patients, particularly in children. Little is known about the epidemiology of analgesic medication errors in patients being discharged from the hospital... expand abstract. The goal of this study was to describe the epidemiology of controlled substance prescription errors by physicians-in-training for children being discharged from the hospital. We conducted a prospective, observational study of the analgesic prescriptions and discharge forms of 241 pediatric patients discharged from a Children's Center of a major urban teaching hospital from November 2003 to April 2004. All patients who were actively followed by the Pediatric Pain Service at the time of their discharge and were discharged with an analgesic prescription were included in the study. Primary outcome variables were the percentage of prescriptions that contained at least 1 medication error or potential adverse drug event. Errors were defined using the Institute for Safe Medication Practices' (ISMP) List of Error-Prone Abbreviations, Symbols, and Dose Designations, literature review, expert panel consensus, and the Johns Hopkins Department of Pharmacy hospital formulary. Two hundred forty-one patients who received 314 prescriptions were included in this study. Prescription errors were common; 257 of 314 (82%) of the prescriptions examined contained 1 or more errors. The most common errors were missing or wrong patient weight (n = 127, 77%), incomplete dispensing information (n = 167, 53%), and no or wrong date on prescription (n = 19, 6%). Nine prescriptions (2.9%) had the potential for significant medical injury and were considered potential adverse drug events. Discharge prescription errors for children requiring potent, opioid analgesic drugs in the management of pain are common, and nearly 3% could cause significant harm. The high rate of prescribing errors highlights the importance of developing, testing and implementing effective error-prevention strategies, especially in high-risk medications such as narcotics. PERSPECTIVE: Narcotic prescriptions written by trainees at discharge from a pediatric hospital are error prone and nearly 3% have the potential to cause significant harm. With a low therapeutic profile, the hospital may consider a review/verification process to reduce the risk of patient harm. collapse abstract

Challenges in reusing transactional data for daily documentation in neonatal intensive care.

The reuse of transactional data for clinical documentation requires navigation of computational, institutional and adaptive barriers. We describe organizational and technical issues in developing and deploying a daily progress note tool in a tertiary... expand abstract neonatal intensive care unit that reuses and aggregates data from a commercial integrated clinical information system. collapse abstract

Visualizing multivariate time series data to detect specific medical conditions.

Efficient unsupervised algorithms for the detection of patterns in time series data, often called motifs, have been used in many applications, such as identifying words in different languages, detecting anomalies in ECG readings, and finding similari... expand abstractties between images. We present a process that creates a personalized multivariate time series representation a Multivariate Time Series Amalgam (MTSA) of physiological data and laboratory results that physicians can visually interpret. We then apply a technique that has demonstrated success with the interpretation of univariate data, named Symbolic Aggregate Approximation (SAX), to visualize patterns in the MTSAs that may differentiate between medical conditions such as renal and respiratory failure. collapse abstract

Effect of a laboratory result pager on provider behavior in a neonatal intensive care unit.

INTRODUCTION: Automated paging systems that inform providers about abnormal laboratory values may alter their behavior. METHODS: We prospectively studied provider behavior before and after implementation of a laboratory paging system that utilizes a ... expand abstractfiltering mechanism. RESULTS: The proportion of laboratory results that were acted upon did not change significantly. However, providers were more likely to order repeat laboratory testing (p = 0.019) CONCLUSION: Provider behavior is altered in the presence of a laboratory paging system. collapse abstract

Efficacy and feasibility of teledermatology for paediatric medical education.

We evaluated a teledermatology consultation service in the education of medical trainees. The selection of cases for consultation was at the discretion of the trainees, who could contact the study team for advice about obtaining photographs and submi... expand abstracttting the case to a web-based system. Asynchronous structured feedback was provided to trainees by an academic paediatric dermatology consultant using a web-based interface. Efficacy was evaluated by examining the trainees' self-reported competency in clinical dermatology skills before and after teleconsultation. A total of 44 trainees (31 residents and 13 medical students) completed 50 consultations. Trainees reported significant improvement (mean improvement 22%, P < 0.002) in competency in five of the six areas assessed. In addition, 88% of trainees were very satisfied with the teaching methodology (> or =5 on a 7-point scale) and 86% were very likely to apply the information in their future practice (> or =5 on a 7-point scale). We believe that teledermatology has great potential in the education of medical trainees. collapse abstract

A World Wide Web-based antimicrobial stewardship program improves efficiency, communication, and user satisfaction and reduces cost in a tertiary care pediatric medical center.

BACKGROUND: Antimicrobial stewardship programs aim to reduce inappropriate hospital antimicrobial use. At the Johns Hopkins Children's Medical and Surgical Center (Baltimore, MD), we implemented a World Wide Web-based antimicrobial restriction progra... expand abstractm to address problems with the existing restriction program. METHODS: A user survey identified opportunities for improvement of an existing antimicrobial restriction program and resulted in subsequent design, implementation, and evaluation of a World Wide Web-based antimicrobial restriction program at a 175-bed, tertiary care pediatric teaching hospital. The program provided automated clinical decision support, facilitated approval, and enhanced real-time communication among prescribers, pharmacists, and pediatric infectious diseases fellows. Approval status, duration, and rationale; missing request notifications; and expiring approvals were stored in a database that is accessible via a secure Intranet site. Before and after implementation of the program, user satisfaction, reports of missed and/or delayed doses, antimicrobial dispensing times, and cost were evaluated. RESULTS: After implementation of the program, there was a $370,069 reduction in projected annual cost associated with restricted antimicrobial use and an 11.6% reduction in the number of dispensed doses. User satisfaction increased from 22% to 68% and from 13% to 69% among prescribers and pharmacists, respectively. There were 21% and 32% reductions in the number of prescriber reports of missed and delayed doses, respectively, and there was a 37% reduction in the number of pharmacist reports of delayed approvals; measured dispensing times were unchanged (P = .24). In addition, 40% fewer restricted antimicrobial-related phone calls were noted by the pharmacy. CONCLUSION: The World Wide Web-based antimicrobial approval program led to improved communication, more-efficient antimicrobial administration, increased user satisfaction, and significant cost savings. Integrated tools, such as this World Wide Web-based antimicrobial approval program, will effectively enhance antimicrobial stewardship programs. collapse abstract

No time to waste: decreasing patient wait times for chemotherapy administration using automated prioritization in an oncology pharmacy system.

OBJECTIVES: To implement an automated pharmacy dispensing prioritization system and to evaluate its effect on the timing of dispensing and administration of chemotherapy. STUDY DESIGN: An electronic chemotherapy dispensing system that prioritized ord... expand abstracters for pharmacy processing based on anticipated patient arrival at the oncology outpatient unit was implemented, followed by an educational intervention for pharmacy staff.Methods: A time-controlled study evaluating the effect of the electronic chemotherapy dispensing system on late, early, and "within target" dispensing and administration of chemotherapy was conducted.RESULTS: A total of 13,138 chemotherapies were prepared and released pending medical clearance based on laboratory results (hereafter referred to as pending counts) (8677 [66.0%]) or pending arrival of the patient (hereafter referred to as pending arrival) (4461 [34.0%]) from March 1, 2005, to March 2, 2006. Chemotherapy dispensing and administration times were retrospectively compared with chemotherapy appointment times after adjustment for late patient arrival. Dispensing times continuously decreased from a mean delay in dispensing of 12 minutes after the adjusted chemotherapy appointment time at baseline to dispensing a mean of 5 minutes ahead of the scheduled time by the end of the study. Chemotherapy treatments dispensed within target increased from 62.9% to 74.7% (pending arrival) and from 53.4% to 68.1% (pending counts), and those administered within target increased from 64.9% to 71.8% (pending arrival) and from 56.0% to 70.1% (pending counts).CONCLUSION: An automated intervention for synchronizing chemotherapy preparation with anticipated times for administration was associated with significant reduction in wait times. collapse abstract

Translational research in medical informatics or from theory to practice. A call for an applied informatics journal.

OBJECTIVE: To bridge the divide between health informatics 'bench research' and the application of informatics in clinical and health care settings. METHOD: Identifying weak points in translational activities, i.e. in the process from health informat... expand abstractics research outcomes to IT system design and information management in clinical practice. RESULTS AND CONCLUSIONS: The creation of a new peer-reviewed journal, designed to cultivate broad readership across health care, is suggested in order to communicate on informatics topics of translational interest and on the application of informatics principals. Such an applied informatics journal may appeal to practicing physicians, healthcare administrators and CIOs as well as medical informaticians. In a globalizing world with eHealth initiatives spanning across borders, such a journal should be an international effort. Close ties to the International Medical Informatics Association (IMIA) and to the journal Methods of Information in Medicine are suggested. collapse abstract

Medication errors in neonates.

Prevention of harm from medication errors has become a national priority. Medication errors in the neonatal intensive care unit are common, and most can be avoided. This article reviews the prevalence and types of medication errors affecting the care... expand abstract of the neonate and summarizes approaches that have been used to reduce these errors. Safety initiatives applicable to minimizing medication errors also are discussed. collapse abstract

Patient safety rounds in a pediatric tertiary care center.

BACKGROUND: Patient safety rounds were implemented in a pediatric tertiary care setting. Completed patient safety issues from three years of pediatric patient safety rounds and nine months of pediatric surgical safety rounds were analyzed. Completed ... expand abstractissues were categorized into both Modified Vincent and University HealthSystem Consortium (UHC) categorization schemes to compare and contrast their attributes. FINDINGS: From January 2003 through January 2006, there were 159 completed patient safety issues, 148 (93%) from general pediatric safety rounds and 11 (7%) from pediatric surgical safety rounds. Using the UHC classification scheme, 35.8% of the issues were classified as care coordination/records, 27.0% as equipment safety situation/preventive maintenance, 21.4% as equipment/supplies/devices, 3.8% as error related to procedure/ treatment/test, and 3.8% as medication error. In the Modified Vincent classification scheme, 63.5% of the issues were classified as environmental factors, 23.3% as team factors, 6.9% as individual factors, 3.1% as task factors, and 1.9% as patient characteristics. Pediatric safety rounds were well received by both frontline staff and senior executives. DISCUSSION: The use of pediatric safety rounds is a low-cost intervention that helps to partner senior leaders and frontline staff on patient safety and is an effective tool for improving patient safety in a pediatric setting. collapse abstract

False-positive results on colorimetric carbon dioxide analysis in neonatal resuscitation: potential for serious patient harm.

A term infant requiring resuscitation was found to have a false-positive color change on a colorimetric carbon dioxide device as a result of administration of epinephrine via an endotracheal tube. Using models of direct application and vapor exposure... expand abstract with a test lung, we discovered that epinephrine, atropine, infasurf and naloxone may result in false-positive color change. This false-positive response may lead to delayed recognition of esophageal intubation. collapse abstract

Capture and classification of problems during CPOE deployment in an academic pediatric center.

During a planned, rapid deployment of a modified commercial CPOE product to units at an academic pediatric center, problems from users and staff were collected and entered in text format on a commercially available online problem tracking system. Con... expand abstracttent analysis of 278 collected text reports collected over 3 weeks after the 24-hour rollout period revealed several themes: center-specific implementation problems (45%), transfer-handoff-collaboration problems (14%), missing product functionalities (11%), inadequate training (11%), hardware problems (5%), password problems (4%) and human error (2%). This analysis may prove helpful in future deployments of CPOE in pediatric clinical environments. collapse abstract

Self-reported treatment patterns in patients with Sturge-Weber syndrome and migraines.

Migraine is common in patients with Sturge-Weber syndrome, yet treatment options are poorly described. An Internet-based questionnaire was completed anonymously by 104 Sturge-Weber syndrome patients, 74 of whom reported experiencing migraines (median... expand abstract age, 25 years; range, 3-64 years). Sixteen (22%) subjects self-reported trying triptans. Five of 12 (42%) describing triptan response believed they were very efficacious (median time of onset of 26 minutes), compared to 13 of 65 (20%) using over-the-counter analgesics (P = .08). Eighty-eight percent (14/16) of triptan users self-reported that when they do not use medications, migraines had a moderate to severe impact on their quality of life; however, while taking triptans, only 50% (7/14) of users reported such an impact (P = .03). Two patients using triptans reported transient unilateral weakness. Of the 26 patients (35%) who received daily preventative medications, 80% experienced improved quality of life. In addition, only 10 of 24 (42%) reported a significant negative impact of migraines on quality of life with daily preventative use, compared to 22 of 26 (85%) without their use (P = .002). Sturge-Weber syndrome patients with migraines are using triptans and preventative agents and self-reporting good efficacy. The small sample size precludes any safety analysis, however, and future prospective trials of both treatment options are needed. collapse abstract

Progressive dilation of the ascending aorta in children with isolated bicuspid aortic valve.

Although patients with bicuspid aortic valves (BAVs) are predisposed to ascending aortic (AA) dilation, stenosis, and dissection, the development of aortic disease in children with BAVs is poorly described. The purposes of this study were to determin... expand abstracte the rate of change of AA diameter in children with BAVs and to identify risk factors for the development of aortic dilation. The echocardiograms of 276 children aged<19 years (mean 8.5+/-5.3) with isolated BAVs were reviewed. Aortic measurements were normalized to z scores on the basis of body surface area. In a subset of 112 patients with serial examinations, aortic growth rates were calculated and risk factors for more rapid aortic growth determined. At presentation, 33 patients (12%) demonstrated marked AA dilation (z>4), and 70 (25%) were moderately abnormal (z between 2 and 4). The mean+/-SD AA diameter increased more than expected, at a rate of 0.18+/-0.30 z score per year (p<0.0001). In 61 patients with normal AA diameters on initial study, 22 (36%) had abnormal diameters, with z scores>2, at follow-up. Univariate analysis demonstrated right-noncoronary commissural fusion (p<0.02) and aortic valve gradient on initial examination (p<0.02) as significant predictors of AA growth. In multivariate analysis, however, the significance of gradient and valve morphology was diminished (p = 0.06 for both). In conclusion, the progression of AA diameter in patients with normal z scores on initial examination suggests that serial echocardiograms are required to screen for the development of significant aortic dilation. collapse abstract

Blocking of pornography-seeking behavior in digital image libraries: adventures in the skin trade.

The escalating competition between online pornography - seeking and disseminating behaviors and technologies that attempt to reduce them creates technical, semantic and legal barriers to the legitimate discussion of and education about sensitive heal... expand abstractth issues involving sexuality, anatomy and pathology, especially when image-based knowledge is used. The effects of this competition on the use and management of an online dermatology atlas are described with a discussion on the importance of anticipating, addressing and controlling this problem while developing and maintaining image-based digital libraries and other e-Health applications. collapse abstract

Workflow and problem domain as information planning tools in a pediatric clinic--defining present and future information technology needs.

In 2002, $22.4 billion were spent on hospital construction in the US. With lifetimes for new buildings expected to be decades, planning a building's information technology infrastructure must take into account present and future needs. Workflow measu... expand abstractrement and the definition of problem domain have been advanced as essential tools in addressing current requirements while anticipating future needs. To examine these, stakeholders must be identified-including both those who will use the facility and those who will be involved in the IT planning and long term support. collapse abstract

Patient safety: a tale of two institutions.

The Johns Hopkins Medical Institutions and the University of Pittsburgh Medical Center are both working to improve patient safety. Johns Hopkins is focused on creating a culture of safety--frontline interventions at its Children's Center include a fo... expand abstractcus on the "Culture of Safety" and three programs that use information technology to "fix the broken medication process." Quantitative data indicate these programs are making care safer. At UPMC, efforts launched under the Robert Wood Johnson Foundation and the Institute of Health Care Improvement, a program named Transforming Care at the Bedside, are redesigning care processes to support nurses and focus on patients. Interventions include family-initiated rapid response teams and other changes designed to streamline processes and use information technology to make care patient-centered. Simulation-based training targets critical procedures and performance for physicians and nurses, and a "smart room" is slated for development. collapse abstract

Computerized provider order entry and patient safety.

Computerized provider order entry (CPOE) and clinical decision support (CDS) are advocated health care information technologies for improving patient safety through reduction and prevention of medication errors. CPOE and DCS target specific errors in... expand abstract medication processes, particularly in prescribing and ordering. These are of particular importance in pediatrics, because children may be more vulnerable to prescribing errors than adults. Studies of CPOE/CDS performed at academic medical centers have demonstrated their effectiveness in reducing medication process errors in pediatrics, but scant data so far show effects on health outcomes. CPOE/CDS adoption requires significant expertise in health care processes, information technology, and change management. Adoption is a high-cost, high-risk venture with political implications. collapse abstract

Patient safety in emergency situations: A web-based pediatric arrest medication calculator.

To prevent adverse drug events for pediatric patients, increase care provider efficiency, and reduce stress for care providers, a technology tool was developed that calculates medication dosage requirements during emergency situations. This article d... expand abstractescribes a simple low-cost technological solution for improving patient safety and care-provider assurance. Follow-up studies provide validation of the technology tool. collapse abstract

Computer based medication error reporting: insights and implications.

BACKGROUND: Despite the growing use of error reporting tools, the healthcare industry is inexperienced in receiving, understanding, and analyzing these reports. OBJECTIVE: To assess the accuracy and define the epidemiology of medication error reports... expand abstract. Design, setting, and patients: A retrospective cohort study of 581 error reports containing 1010 medication errors reported between July 2001 and January 2003 at a large academic children's institution. MAIN OUTCOME MEASURES: Correct classification and types of medication errors. RESULTS: Of the 1010 medication errors reviewed, 298 (30%) were prescribing errors, 245 (24%) were dispensing errors, 410 (41%) were administration errors, and 57 (6%) involved medication administration records (MAR). Following expert review, 208 errors (21%) were deleted because they had been inappropriately coded as errors and 97 (10%) were added as they were not initially coded despite having occurred. In addition, 352 medication error reports needed to have the subtype of error reclassified; 207 (59%) of these involved the reporter choosing the non-descript "other" category on the reporting tool (such as "Prescribing other") which was able to be reclassified by expert review. The overall distribution of error type categories did not change significantly with expert review, although only MAR errors were underreported by the reporters. The most common medications were anti-infectives (17%), pain/sedative agents (15%), nutritional agents (11%), gastrointestinal agents (8%), and cardiovascular agents (7%). CONCLUSIONS: Despite clear imperfections in the data captured, medication error reporting tools are effective as a means of collecting reliable information on errors rapidly and in real time. Our data suggest that administration errors are at least as common as prescribing errors in children. Further research is needed, not only in the area of computerized physician order entry (CPOE) for children, but also on ways to make the dispensing and administration of medications safer. collapse abstract

Decreasing errors in pediatric continuous intravenous infusions.

OBJECTIVE: To evaluate the effect of a Web-based calculator and decision-support system on infusion ordering errors and to estimate error frequency in pharmacy infusion preparation. DESIGN: Data on ordering error frequency and typology were collected... expand abstract before and after implementation of an online infusion ordering system. Data on pharmacy preparation errors of infusions were collected. SETTING: A children's hospital at an academic medical center. PATIENTS: None. Data were abstracted from infusion orders. INTERVENTIONS: Introduction of a voluntary-use Web-based calculator into infusion ordering workflow. Observation only. MAIN OUTCOME MEASURES: Number and type of errors in handwritten and calculator-generated orders. Number and type of errors in pharmacy infusion preparation. RESULTS: Before calculator deployment, 129 sequential handwritten infusion orders were collected over 5 weeks. After deployment, of 162 sequential infusion orders, 88% (142) were calculator-generated. Calculator-generated infusion orders contained 83% fewer (p < .001) orders containing one or more errors than handwritten orders. Calculator-generated orders contained no high-risk errors (incorrect decimal, dose, or unit of measure) when compared with handwritten orders and were associated with fewer pharmacy interventions. In 118 sequential pharmacy infusion preparations over 4 wks, there were no errors observed. CONCLUSION: A Web-based calculator reduced significantly the total number of errors and eliminated all high-risk errors in the prescribing process for continuous pediatric infusions. With no observed errors in pharmacy preparation, this study provides data to support the use of computerized ordering as an independent safe and viable method for ordering continuous pediatric infusions. collapse abstract

Error reduction in pediatric chemotherapy: computerized order entry and failure modes and effects analysis.

OBJECTIVE: To implement and evaluate the impact of computerized provider order entry (CPOE) on reducing ordering errors in pediatric chemotherapy. DESIGN: Before-and-after study from 2001 to 2004. SETTING: Pediatric Oncology in an academic medical ce... expand abstractnter. INTERVENTION: Implementation of a CPOE system guided by multidisciplinary failure modes and effects analysis into pediatric chemotherapy. MAIN OUTCOME MEASURES: Completion data on chemotherapy steps of high morbidity/mortality potential if missed (as determined by attending oncologists) from 1259 pre-CPOE paper and 1116 post-CPOE pediatric chemotherapy orders. RESULTS: After CPOE deployment, daily chemotherapy orders were less likely to have improper dosing (relative risk [RR], 0.26; 95% confidence interval [CI], 0.11-0.61), incorrect dosing calculations (RR, 0.09; 95% CI, 0.03-0.34), missing cumulative dose calculations (RR, 0.32; 95% CI, 0.14-0.77), and incomplete nursing checklists (RR, 0.51; 95% CI, 0.33-0.80). There was no difference in the likelihood of improper dosing on treatment plans and a higher likelihood of not matching medication orders to treatment plans (RR, 5.4; 95% CI, 3.1-9.5). CONCLUSION: Failure modes and effects analysis-guided CPOE reduced ordering errors in pediatric chemotherapy and provided data for further improvements. collapse abstract

Perceived increase in mortality after process and policy changes implemented with computerized physician order entry.