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Published on: June 11, 2012
The pitfalls of electronic health orders: development of an enhanced institutional protocol after a preventable
Brandon J Manley1, Rebecca K Gericke2, John A Brockman2
1Division 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.
Insights
Continuous bladder irrigation (CBI) poses risks when administered by non-urologists. Revisions to order sets, including removing infusion rates and adding alerts, improve safety and provider understanding of CBI complications.
Area of Science:
- Urology
- Medical Safety
- Healthcare Administration
Background:
- Continuous bladder irrigation (CBI) is a standard treatment for gross hematuria and acute bladder conditions.
- Traditionally managed by urologists, CBI is increasingly administered by non-specialist providers in large hospitals.
- This shift can lead to unfamiliarity with CBI protocols and potential complications.
Purpose of the Study:
- To identify and address safety hazards associated with non-urologist-administered CBI.
- To improve the understanding and safe administration of CBI by healthcare providers.
- To reduce the risk of complications such as bladder perforation.
Main Methods:
- Analysis of 136 CBI orders placed by non-urologic providers in 2013.
- Expert panel review of CBI order sets and administration practices.
- Development and implementation of revised electronic order sets with safety features.
Main Results:
- Non-urologic providers and nurses often lacked knowledge of CBI dysfunction signs and symptoms.
- The requirement for an infusion rate in orders led to inappropriate use of infusion pumps, increasing perforation risk.
- Providers were unfamiliar with medication dosing for managing CBI-related discomfort.
Conclusions:
- Revising order sets to remove infusion rate requirements and add warnings improved staff comprehension.
- Implementing Computerized Provider Order Entry (CPOE) alerts recommending urology consultation enhanced safety.
- Adding communication boxes for signs/symptoms and troubleshooting guides improved management of CBI dysfunction.
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.
Findings:
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.
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