A Quality Improvement Initiative to Decrease Platelet Ordering Errors and a Proposed Model for Evaluating Clinical...

Area of Science:

• Healthcare Informatics
• Patient Safety
• Clinical Decision Support Systems

Background:

• Clinical decision support (CDS) and computerized provider order entry can improve healthcare quality and safety but may introduce errors.
• Multiple CDS tools exist for platelet transfusion orders, necessitating evaluation of their effectiveness.
• Unanticipated errors from CDS tools require systematic identification and mitigation strategies.

Purpose of the Study:

• To evaluate and enhance the effectiveness of existing CDS tools for platelet transfusion orders.
• To develop and test a framework for evaluating other CDS tools.
• To reduce platelet undertransfusion ordering errors.

Main Methods:

• Retrospective analysis of enterprise data warehouse at a pediatric hospital to assess baseline CDS performance for platelet transfusion orders.
• Defined ordering errors as platelet transfusion volumes less than recommended by the order set.
• Prospective evaluation of redesigned CDS using statistical process control methodology.

Main Results:

• Two order sets accounted for 62% of platelet transfusion orders.
• Inpatient Service 1 order set showed a higher error rate (3.10%) compared to Inpatient Service 2 (1.20%).
• Post-intervention, platelet transfusion order errors on Inpatient Service 1 decreased from 3.10% to 0.33%.

Conclusions:

• Redesigning CDS tools effectively reduced platelet transfusion ordering errors.
• Clinical data analysis can uncover previously undetected ordering error patterns.
• A framework was established for evaluating the effectiveness of similar CDS tools.