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The pitfalls of electronic health orders: development of an enhanced institutional protocol after a preventable patient death

机译：电子医疗命令的陷阱：可预防的患者死亡后制定增强的机构规程

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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.
机译：背景技术持续膀胱冲洗术（CBI）是用于治疗严重血尿和其他急性膀胱疾病的长期治疗方法。传统上，它的使用仅限于直接泌尿科护理的患者，但是由于现代大型医院医疗保健的限制，许多患者接受了由不熟悉它的使用和潜在并发症的医疗服务提供者进行的CBI。调查结果2013年，非泌尿外科医师下达了136份CBI订单。我们分析中发现的最大危害是输入灌溉管理速率的要求。没有CBI经验的护士将此命令视为通过输液泵进行给药的指示，这很容易超过膀胱的机械完整性，并增加了膀胱穿孔的风险。我们的小组还发现，由于护士和非泌尿外科医师缺乏经验，CBI功能障碍的体征和症状并非常识。我们还发现，非泌尿外科医师不熟悉CBI患者的给药和用药剂量，以帮助CBI患者内在不适。结论在修订的订单集中，我们发现消除对输液速度的要求以及在CPOE中放置警告可以帮助工作人员更好地理解这种可能的并发症。我们在CPOE中创建了最佳实践警报，强烈建议您咨询泌尿科服务。通讯文本框已添加到订单集中，以帮助工作人员了解CBI功能障碍的体征和症状，以及解决问题的指南。

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