The current investigation has 2 key findings. First, prescribing contraindicated antithrombotic medications is not infrequent in patients with severe CKD admitted with ACS, occurring in 10% of our cohort, and is associated with a 6-fold increased risk of in-hospital bleeding. Second, CPOE with decision support is an effective tool in reducing the frequency of medication errors in this population.
Since 2000, when the Institute of Medicine (IOM) issued its report “To Err Is Human: Building a Safer Health System,” there has been a greater focus on medical errors, particularly medication errors in hospitalized patients.1
That same year, 47% of respondents in a US survey of health care consumers indicated that they were “very concerned” about a medical error resulting in injury when they went to a hospital for care, leading Congress to pass the Medicare Modernization Act, which charged the IOM to formulate a national agenda focused on reducing medication errors.6,23
Although the IOM’s report stated that “the problem is not bad people; the problem is that the system needs to be made safer,” medication errors continue to occur with significant frequency in patients hospitalized with cardiovascular conditions. A 5-year study reported a rate of 24 medication errors per 100 admissions, attributed primarily to prescribers.24
The elderly and patients with CKD have recently been identified as high-risk groups for medication errors in ACS. Similarly, antithrombotics have been identified as medications at risk for causing harm, or “high-alert medications,” in ACS.4,6,7
A recent American Heart Association guideline statement entitled “Medication Errors in Acute Cardiovascular and Stroke Patients” focuses on these facts and further recommends use of CPOE as a system improvement to promote medication safety.6
To our knowledge, this investigation is the first to assess the impact of CPOE with decision support in a high-risk group in the acute cardiovascular setting.
Key components to this successful implementation were to integrate CPOE with decision support into the daily work flow, provide limited computer support to key decisions, offer recommendations in addition to assessments, and use alert-based or automatic decision support rather than an on-demand system.25
Limitations to this study were the relatively small sample size and the lack of prospective randomization. Although the use of CPOE with decision support was not randomized, raising the possibility of some selection bias, the baseline characteristics of patients managed with and without CPOE were similar except for a higher TIMI risk in the CPOE group. Therefore, it is possible that the ordering physician was more careful with higher-risk patients, which could have influenced the outcome. Importantly, however, the clinician initiating the orders was generally not the cardiologist managing the patient during hospitalization, thus reducing the chance that this initial choice of orders influenced other aspects of medical care. However, patients did continue the treatment regimen initiated by the admission orders in essentially all cases. As a result, we think that our conclusions remain valid and support the use of CPOE with decision support to promote medication safety in patients with ACS.