title: Analysis of electronic medication orders with large overdoses: opportunities for mitigating dosing errors.
abstract: BACKGROUND
  Users of electronic health record (EHR) systems frequently prescribe doses outside recommended dose ranges, and tend to ignore the alerts that result. Since some of these dosing errors are the result of system design flaws, analysis of large overdoses can lead to the discovery of needed system changes.
  
  
  OBJECTIVE
  To develop database techniques for detecting and extracting large overdose orders from our EHR. To identify and characterize users' responses to these large overdoses. To identify possible causes of large-overdose errors and to mitigate them.
  
  
  METHODS
  We constructed a data mart of medication-order and dosing-alert data from a quaternary pediatric hospital from June 2011 to May 2013. The data mart was used along with a test version of the EHR to explain how orders were processed and alerts were generated for large (>500%) and extreme (>10,000%) overdoses. User response was characterized by the dosing alert salience rate, which expresses the proportion of time users take corrective action.
  
  
  RESULTS
  We constructed an advanced analytic framework based on workflow analysis and order simulation, and evaluated all 5,402,504 medication orders placed within the 2 year timeframe as well as 2,232,492 dose alerts associated with some of the orders. 8% of orders generated a visible alert, with ¼ of these related to overdosing. Alerts presented to trainees had higher salience rates than those presented to senior colleagues. Salience rates were low, varying between 4-10%, and were lower with larger overdoses. Extreme overdoses fell into eight causal categories, each with a system design mitigation.
  
  
  CONCLUSIONS
  Novel analytic systems are required to accurately understand prescriber behavior and interactions with medication-dosing CDS. We described a novel analytic system that can detect apparent large overdoses (≥500%) and explain the sociotechnical factors that drove the error. Some of these large overdoses can be mitigated by system changes. EHR design should prospectively mitigate these errors.
authors.forename: E S
authors.initials: ES
authors.lastname: Kirkendall
authors.affiliation: Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center , Cincinnati, Ohio.
authors.forename: M
authors.initials: M
authors.lastname: Kouril
authors.forename: T
authors.initials: T
authors.lastname: Minich
authors.forename: S A
authors.initials: SA
authors.lastname: Spooner
mesh_terms: D000082:Acetaminophen / Q000008:administration & dosage / Q000494:pharmacology; D019992:Databases as Topic; D062787:Drug Overdose; D006801:Humans; D007263:Infusions, Parenteral; D050316:Medical Order Entry Systems; D008508:Medication Errors / Q000517:prevention & control*; D008510:Medication Systems, Hospital; D008727:Methotrexate / Q000008:administration & dosage / Q000494:pharmacology
chemical_list: D000082:Acetaminophen; D008727:Methotrexate
keywords: CPOE; Electronic health record; clinical decision support systems; electronic medical record; medical order entry system
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