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Preventing Perioperative Medication Errors and Adverse Drug Events Through the Use of Clinical Decision Support

Project Final Report (PDF, 503.69 KB) Disclaimer

Project Details -
Completed

In the United States alone, approximately 15.75 million medication errors occur annually in operating rooms. Almost half of these lead to patient harm, with the remainder having the potential for harm. While not yet widely used in operating rooms, clinical decision support (CDS) systems have been shown to prevent medication errors and their associated harm in other patient care areas and have the potential to prevent more than 50 percent of medication errors and 95 percent of adverse drug events in the operating room.

This project, funded under a Mentored Clinical Scientist Research Career Development Award, will develop a CDS tool for the perioperative setting and evaluate whether the use of decision support in this setting improves patient safety by preventing medication errors and adverse drug events.

The specific aims of this project are as follows:

  • Design, prioritize, and tier evidence-based CDS rules for the perioperative setting 
  • Build and implement a perioperative CDS tool that interfaces with existing electronic health records 
  • Evaluate whether the CDS system reduces the incidence of perioperative medication errors and preventable adverse drug events 

An expert panel using a modified Delphi approach will validate the developed CDS rules. Those rules will form the basis of the perioperative tool. The evaluation will consist of an interrupted time series analysis, complemented by qualitative analysis of semistructured user interviews. This will be followed by a randomized controlled trial to assess the incidence of medication errors and adverse drug events, with and without the CDS system.