title: The pitfalls of electronic health orders: development of an enhanced institutional protocol after a preventable patient death.
abstract: BACKGROUND
  Continuous bladder irrigation (CBI) is a long-standing treatment used in the setting of gross hematuria and other acute bladder issues. Its use has traditionally been reserved for patients under direct urologic care, but with the constraints of modern large-hospital healthcare, many patients have CBI administered by providers unfamiliar with its use and potential complications.
  
  
  RESULTS
  There were 136 CBI orders placed in 2013 by non-urologic providers. The biggest hazard found in our analysis was the requirement for entering a rate of irrigation administration. Nurses with no experience with CBI viewed this order as an indication to administer via an infusion pump, which can easily exceed the mechanical integrity of the bladder and increase the risk of bladder perforation. Our panel also found that due to lack of experience by nurses and non-urologic providers, that signs and symptoms of CBI dysfunction were not common knowledge. Also we found that non-urologic providers were unfamiliar with administration and dosing of medications for CBI patients to help with the intrinsic discomfort with CBI administration.
  
  
  CONCLUSIONS
  In our revised order set we found that removing the requirement for an infusion rate, along with placing warnings in the CPOE, helped staff better understand this possible complication. We created a best practice alert in our CPOE to strongly recommend the urology service be consulted. Communication text boxes were added to the order set to help staff be aware of the signs and symptoms of CBI dysfunction, along with a guide for trouble shooting.
authors.affiliation: Division of Urology, Department of Surgery, Washington University in St. Louis, St. Louis, MO USA ; Division of Urologic Surgery, Washington University School of Medicine, 4960 Children's Pl., Campus, Box 8242, St. Louis, MO 63110 USA.
authors.forename: Brandon J
authors.initials: BJ
authors.lastname: Manley
authors.affiliation: Division of Urology, Department of Surgery, Washington University in St. Louis, St. Louis, MO USA.
authors.forename: Rebecca K
authors.initials: RK
authors.lastname: Gericke
authors.affiliation: Division of Urology, Department of Surgery, Washington University in St. Louis, St. Louis, MO USA.
authors.forename: John A
authors.initials: JA
authors.lastname: Brockman
authors.affiliation: Division of Urology, Department of Surgery, Washington University in St. Louis, St. Louis, MO USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Robles
authors.affiliation: Division of Urology, Department of Surgery, Washington University in St. Louis, St. Louis, MO USA.
authors.forename: Valary T
authors.initials: VT
authors.lastname: Raup
authors.affiliation: Division of Urology, Department of Surgery, Washington University in St. Louis, St. Louis, MO USA.
authors.forename: Sam B
authors.initials: SB
authors.lastname: Bhayani
keywords: Communication; Consultants; Delivery of health care; Hematuria; MeSH; Urinary bladder