Answer
Introduction
Evidence-Based Practice (EBP) is well defined as the practical integration of evidence, clinical expertise, and patients’ preferences to enhance individualized care and increase the quality of care delivered. Studies have shown that organizations that continuously employ evidence-based practice have better patient outcomes with reduced medical errors, cost of care, and lower patient mortality rate (Yoo et al., 2019). The huge existent database of peer-reviewed scientific journals has dramatically impacted the use of the evidence-based practice. EBP also helps nurses stay updated about the new medical protocols, thus improve their skills resulting in better productivity. This paper aims to utilize a critical appraisal tool to evaluate four peer-reviewed articles, thus suggesting the best practice that emerges from the review.
Evaluation Table
Evidence-Based Practice (EBP)
Full APA formatted citation of selected article. Article #1 Article #2 Article #3 Article #4
1. Scott, I. A., Pillans, P. I., Barras, M., & Morris, C. (2018). Using EMR-enabled computerized decision support systems to reduce prescribing of potentially inappropriate medications: a narrative review. Therapeutic advances in drug safety, 9(9), 559–573. https://doi.org/10.1177/2042098618784809
1. Patel, J., Ogletree, R., Sutterfield, A., Pace, J. C., & Lahr, L. (2016). Optimized Computerized Order Entry can Reduce Errors in Electronic Prescriptions and Associated Pharmacy Calls to Clarify (CTC). Applied clinical informatics, 7(2), 587–595. https://doi.org/10.4338/ACI-2015-10-RA-0140
Prgomet, M., Li, L., Niazkhani, Z., Georgiou, A., & Westbrook, J. I. (2017). Impact of commercial computerized provider order entry (CPOE) and clinical decision support systems (CDSSs) on medication errors, length of stay, and mortality in intensive care units: a systematic review and meta-analysis. Journal of the American Medical Informatics Association : JAMIA, 24(2), 413–422. https://doi.org/10.1093/jamia/ocw145
Nuckols, T. K., Smith-Spangler, C., Morton, S. C., Asch, S. M., Patel, V. M., Anderson, L. J., Deichsel, E. L., & Shekelle, P. G. (2014). The effectiveness of computerized order entry at reducing preventable adverse drug events and medication errors in hospital settings: a systematic review and meta-analysis. Systematic reviews, 3, 56. https://doi.org/10.1186/2046-4053-3-56
Evidence Level *
(I, II, or III)
Level II Level I Level II Level II
Conceptual Framework
Describe the theoretical basis for the study (If there is not one mentioned in the article, say that here).**
The paper targeted a scientific assessment of the process and outcome of incorporating CDSS and CPOE into Electronic Medical Records. The major focus was to see if this intervention can greatly reduce the prescription of potentially inappropriate medications (PIMs).
The paper focused on the determination of whether the optimization of CPOE can help in the reduction of errors in electronic prescriptions. It also tried to identify whether CPOE optimization can reduce frequent pharmacist intervention, especially the need to clarify prescriptions from prescribers. The paper focusses on identifying the significance of cope and CDSS especially in the reduction of medication errors, length of patient stay and mortality rates in ICUs. The paper emphasized assessing the effectiveness of CPOE in reducing adverse drug reactions and medical errors in hospitals.
Design/Method
Describe the design and how the study was carried out (In detail, including inclusion/exclusion criteria). Th study searched scientific databases for articles on EMR-enabled CDSS That helped prescribers make changes when ordering potentially inappropriate medications. Articles excluded included those covering the use of CDSS and limited medication reconciliation, general formulary data, checks of medication errors and dose checks. The key considerations in article selection included outcome measures of medication-related processes and adverse drug reactions and qualitative data on factors affecting the effectiveness of EMR with CDSS. The study involved optimization through the implementation of line validation messages. The messages were generated when; the order failed to specify the provider/pharmacy, Failure to reach DE requirements, and character limits were exceeded especially with patient sig or demographics and absence or incomplete administration instructions.
Prescriptions were selected 9months before and after implementing changes and analyzed by nurses/pharmacists for errors and statistically compared to determine the effectiveness of the change.
The search strategy involved searching for a paper published between January 2000 and January 2016 using three databases; CINAHL, Embase and Medline. Inclusion criteria included articles with reports on ICU setting, with analysis of impacts of CPOE with or without CDSS, indicating quantitative data on medication errors, mortality and length of stay in ICU and finally studies that are RCTs or quasi-experimental study design.
Since the paper is a systematic review, its design involved selecting relevant articles from scientific databases like MEDLINE and Cochrane library. Selection criteria needed that the study compares CPOE with a paper-order entry in health facilities and demonstrate the prevalence of preventable adverse drug events (pADEs) or medical errors. The study excluded articles with children as the population as well as studies with limited event-detection techniques. The pooling of data involved the utilization of random-effects models.
Sample/Setting
The number and characteristics of
patients, attrition rate, etc. The studies collected included RCT conducted in hospitals, ambulatory care clinics and residential aged care facilities (RACFS). Different populations were involved in the studies, but the majority were elderly.
The research was conducted in
university hospital (Mississippi Medical Centre) and included 602 prescriptions for patients who are majorly students and staff of the facility. The study included patients in ICU setups.20 studies were identified The setting of the selected studies included acute care hospital. Sixteen studies were selected with six of these addressing pADEs
Major Variables Studied
List and define dependent and independent variables The dependent variable was EMR-enabled computerized decision support system. This variable was necessary for the evaluation of its significance in reducing errors.
The independent variable is the prescription of PIMs. The dependent variable was the optimized CPOE. The study targeted at identifying the benefits accrued from the modification of this variable. The independent variable is the electronic prescriptions which occur by default in all CPOE systems. The dependent variable in this paper is CPOE and CDSS. This variable is the intervention being tested for its effectiveness.
The independent variables include medication errors, length of stay and mortality rates in ICU units. The dependent variable is the use of CPOE. Presence or absence of this system determines the outcome of the study.
The independent variable includes medication errors and pADEs.
Measurement
Identify primary statistics used to answer clinical questions (You need to list the actual tests done). Twenty studies were identified with 10 RCTs and ten observational studies. Each study was classified as either indicating the usefulness of the lack of, in the reduction of prescription of PIMs. In totality, all the papers indicated the effectiveness of the EMR with CDSS in reducing the clinical issue. The study used a two-tailed model where 270 prescriptions were used in each group to detect a decrease in pharmacy call to clarity (CTC) from 25% to 15% for almost 1005 power and 0.05 P-value. The identified errors pre and post-intervention were then subjected to a contingency table (2×2) and the error rate compared using chi-square tests, risk ratios and odds ratio. Cost calculations were based on the assumption that each pharmacists’ time costs $3.47 per call, and physician time at $4.74 per call. This data was used in the development of a conservative cost analysis.
After selecting articles that meet desired criteria, data extraction followed, including the year of publication, authors, year study was conducted, type of ICU, study design, number of participants and the system used (CPOE/CDSS) and duration of implementation. The quality assessment involved the utilization of Effective Public Health Practice Project tool for quantitative studies. The search strategy involved eight databases and nine websites. The keywords were used to identify the appropriate studies with the exclusion of pediatric studies and those with incidence reporting. A standardised form was used in data extraction. Extracted data includes the number of medical errors and pADEs and value of the exposure level to pADEs or medication errors.
Data Analysis Statistical or
Qualitative findings
(You need to enter the actual numbers determined by the statistical tests or qualitative data). Eight studies were conducted in hospitals, 9 in care clinics and 3 in RACFs. In hospitals, all experimental and observational studies showed a significant reduction in the prescription of PIMs. On utilization of EMR enabled CDSS. One study showed a drop of PIMs from 5.4% to 3.4% post-intervention. The results are also similar to those studies conducted in care clinic with one observational study indicating only 24% of PIMs prescription occurred with setup EMRs with CDSS compared to 42% in control groups.
The analysis also provided similar information on studies conducted in residential care.
Out of the 602 randomly selected e-prescriptions, 61/301 (20.27%) and 39/301 (12.96%) errors were identified by the nurses and pharmacist pre-and post-optimization. Statistical significance of the errors was inline with Pearson chi-square of 5.8 (p=0.016, p<0.05). Cost analysis indicated a $76 cost-saving for every 100 prescription post-optimization. Statistical analysis involved evaluating studies that demonstrate the outcome of CPOE and those that combined CPOE and CDSS. The next action was the grouping of outcome measures of each study. Data obtained were subjected to analysis by identifying the mean, median, interquartile ranges and standard deviation. The relative risk of the outcome measure was calculated. Forest plots were used to present meta-analyses results and chi-square and I2 statistics used to evaluate study heterogeneity. DerSimonian-Laird random-effect model was used in the conduction of meta-analysis for the two outcomes. The risk ratio of each study was calculated. Heterogeneity was so identified when the I2 value was 50%or more and when the p-value for the Q statistics was equal or less than 0.05 Findings and Recommendations General findings and recommendations of the research In totality, all the evidence suggests that EMR-enabled CDSS effectively reduces prescribing of PIMs majorly in hospitals (50%). There is less reduction in the problem in ambulatory care facilities (23%) and borderline effectiveness in RACFs. Optimization of CPOE greatly helps in the reduction of errors. In the process, the number of e-prescriptions also processed increases due to a drop in the number of CTC from pharmacists. Optimization of CPOE also helps in the reduction of the overall cost of service delivery. Use of CPOE in ICU units was found to reduce medical prescription errors by 85%. However, CPOE does not affect the length of stay. The studies indicate that CPOE reduces mortality risk in ICU units by 12%. CPOE significantly reduces pADE in adults in hospitals. The use of CPOE reduces the pADEs and medication errors by half as compared to the paper-ordering system. It is therefore recommended to use CPOE in acute care settings. Appraisal and Study Quality Evidence-Based Practice (EBP)
Describe the general worth of this research to practice.
What are the strengths and limitations of study?
What are the risks associated with implementation of the suggested practices or processes detailed in the research?
What is the feasibility of use in your practice? This study provides quite interesting results by giving efficacy of using EMR-enabled CDSS in different setups. It welcomes the inclusion of other interventions for areas where the intervention provides less desired results. It is appropriate in answering our clinical question since the results favour use of the intervention in hospitals.
The study is clear and well developed in determining a suitable intervention. However, several studies give confusion and require extra time to comprehend each piece of information.
The intervention only caters for the medical errors associated with the prescribing of PIMs. It implies that the effectiveness of this intervention in reducing other medical errors is unknown. Similarly, the results only show a 50% reduction below average, thus proving risky unless used alongside other interventions.
With sufficient funding to install the intervention can produce good results. It will also require employee training and maintenance with constant quality improvement by the inclusion of other interventions. The study provides trusted data, but there is a need to conduct a similar study with bigger sample size. It also helps clarify why there is a need for optimization of CPOE and not just installing the system.
The design of the study gives it superiority since it has both pre-and post-optimization analysis. However, the cost analysis is quite unreliable since each handled prescription’s cost depends on the salary of each staff and the number of prescriptions generated daily.
The optimization is dependent on the kind of patient handled in the facility as such, the actual optimization may work with one hospital and fail in the other.
The intervention is quite practical, especially in institutions that already have a fully functional CPOE. Optimization is less expensive and can work alongside other interventions. The results indicate that CPOE is a good intervention in reducing medical errors and the risk of mortality in inpatient setups. However, success is accelerated if CDSS is also included in the system. However, the length of stay is an outcome that is not affected by the use of CPOE. These results demonstrate that ICU units must be fully equipped with the CPOE and CDSS. The study gives genuine results due to its stringency in identifying the articles to use; however, it is only biased to one setting: ICU units.
The risk of this data implementation is that it might not work for pediatric patients since the data is only limited to adults. Thus there is a need to conduct a different review on pediatric units use of CPOE. Similarly, the expense involved is high since it calls for a combination of both CPOE and CDSS to manage medical errors and mortality risks better.
This intervention works well in a well-established institute with sufficient financial muscles. This paper clarifies that CPOE is significant in reducing pADEs and medical errors, especially in acute care hospitals. This information is vital since it gives data regarding different setup in the hospitals.
The study is a systematic review as such, it is clear and relies on many studies as such the information can be trusted. One limitation is that some of the studies used are tool old (later than 2007).
By using old studies, the information can be considered unreliable, and it might produce unexpected results in the current setups.
However, the use of CPOE is applicable in setups that can purchase the necessary systems and desire to improve the quality of care.
Key findings
EMR-enabled with CDSS gives 50% reduction of prescribing of PIMs in hospitals, thus reduce the intensity of medical errors. Installation f CPOE alone is not effective in reducing medical errors. There is need to optimize the systems to give more than 50% results. CPOE and CDSS, when used together, improve the quality of patient care by reducing medical errors and mortality risks, especially in ICU patients. However, other interventions need to be included to reduce the length of stay in the units. CPOE has the potential of reducing pADEs and medication errors by 50%.
Outcomes
Increased quality of care to patients, reduction of adverse drug events, increased patient safety, easy retrieval of patient data and communication among healthcare practitioners Optimized CPOE reduces the number of prescriptions processed; it also reduces prescription and ultimate cost savings errors. Inclusion of “location” field is important in helping the pharmacist guide the patient on drug administration. This is important especially in dermatological prescriptions. Increased quality of care with a significant reduction in medical errors and reduced mortality risks of patients. Improved service delivery through the reduction of medical errors and preventable adverse drug events.
General Notes/Comments This article shows that the installation of EMR- enabled with CDSS is a reliable method of reducing medical errors. However, the results are diminished in other setups like ambulatory care centres. Quality improvement process in reducing medial errors requires constant optimization of CPOE. This helps in reducing medical errors and promotes cost reduction in running health facilities. CPOE and SDSS produce better results when used together. Hospitals need to install CPOE if they intend to reduce medication errors and pADEs.
*These levels are from the Johns Hopkins Nursing Evidence-Based Practice: Evidence Level and Quality Guide
• Level I
Experimental, randomized controlled trial (RCT), systematic review RTCs with or without meta-analysis
• Level II
Quasi-experimental studies, systematic review of a combination of RCTs and quasi-experimental studies, or quasi-experimental studies only, with or without meta-analysis
• Level III
Nonexperimental, systematic review of RCTs, quasi-experimental with/without meta-analysis, qualitative, qualitative systematic review with/without meta-synthesis
• Level IV
Respected authorities’ opinions, nationally recognized expert committee/consensus panel reports based on scientific evidence
• Level V
Literature reviews, quality improvement, program evaluation, financial evaluation, case reports, nationally recognized expert(s) opinion based on experiential evidence
**Note on Conceptual Framework
• The following information is from Walden academic guides which helps explain conceptual frameworks and the reasons they are used in research. Here is the link https://academicguides.waldenu.edu/library/conceptualframework
• Researchers create theoretical and conceptual frameworks that include a philosophical and methodological model to help design their work. A formal theory provides context for the outcome of the events conducted in the research. The data collection and analysis are also based on the theoretical and conceptual framework.
• As stated by Grant and Osanloo (2014), “Without a theoretical framework, the structure and vision for a study is unclear, much like a house that cannot be constructed without a blueprint. By contrast, a research plan that contains a theoretical framework allows the dissertation study to be strong and structured with an organized flow from one chapter to the next.”
• Theoretical and conceptual frameworks provide evidence of academic standards and procedure. They also offer an explanation of why the study is pertinent and how the researcher expects to fill the gap in the literature.
• Literature does not always clearly delineate between a theoretical or conceptual framework. With that being said, there are slight differences between the two.
Conclusion
All the papers selected were of level I and II. This is important since it demonstrates that the supported data is more conclusive and fit for evidence-based practice. The use of systematic reviews helps in reducing the workload since it contains a summary of several papers. Systematic reviews also have the significance of identifying existing gaps in research, thus helping in further research activities (Yoo et al., 2019). The four articles indicate that the use of CPOE dramatically reduces the occurrence of medical errors. However, Use of CPOE with CDSS provides better results as compared to using CPOE alone (Patel et al., 2016). Therefore, it is recommended for an organization to use CPOE with CDSS to increase the quality of care and reduce the overall cost of treatment.
Question
A rubric lists grading criteria that instructors use to evaluate student work. Your instructor linked a rubric to this item and made it available to you.
Part 3A: Critical Appraisal of Research Conduct a critical appraisal of the four peer-reviewed articles you selected and analyzed by completing the Critical Appraisal Tool Worksheet Template. Be sure to include: • An Evaluation Table
Part 3B: Evidence-Based Best Practices Based on your appraisal, suggest a best practice that emerges from the research you reviewed. Briefly explain the best practice, justifying your proposal with APA citations of the research.
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction is provided which delineates all required criteria
To Prepare:
• Reflect on the four peer-reviewed articles you selected in Module 2 and the four systematic reviews (or other filtered high- level evidence) you selected in Module 3.
• Reflect on the four peer-reviewed articles you selected in Module 2 and analyzed in Module 3.
• Review and download the Critical Appraisal Tool Worksheet Template provided in the Resources.
The Assignment (Evidence-Based Project)
Part 3A: Critical Appraisal of Research
Conduct a critical appraisal of the four peer-reviewed articles you selected by completing the Evaluation Table within the Critical Appraisal Tool Worksheet Template. Choose a total of four peer- reviewed articles that you selected related to your clinical topic of interest in Module 2 and Module 3.
Note: You can choose any combination of articles from Modules 2 and 3 for your Critical Appraisal. For example, you may choose two unfiltered research articles from Module 2 and two filtered research articles (systematic reviews) from Module 3 or one article from Module 2 and three articles from Module 3. You can choose any combination of articles from the prior Module Assignments as long as both modules and types of studies are represented.
Part 3B: Critical Appraisal of Research
Based on your appraisal, in a 1-2-page critical appraisal, suggest a best practice that emerges from the research you reviewed. Briefly explain the best practice, justifying your proposal with APA citations of the research.
Resources
Those are the references for Module 3 – M3W4 # 137776
Alharbi, W., Cleland, J., & Morrison, Z. (2019). Addressing medication errors in an adult oncology department in Saudi Arabia: A qualitative study. Saudi pharmaceutical journal : SPJ : the official publication of the Saudi Pharmaceutical Society, 27(5), 650–654. https://doi.org/10.1016/j.jsps.2019.03.007
Davies, K. S. (2011). Formulating the evidence based practice question: A review of the frameworks for LIS professionals. Evidence Based Library and Information Practice, 6(2), 75–80. https://doi.org/10.18438/B8WS5N
Melnyk, B. M., & Fineout-Overholt, E. (2018). Evidence-based practice in nursing & healthcare: A guide to best practice (4th ed.). Philadelphia, PA: Wolters Kluwer
Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2020). Medical Error Prevention. In StatPearls. StatPearls Publishing.
Stillwell, S. B., Fineout-Overholt, E., Melnyk, B. M., & Williamson, K. M. (2010). Evidence-based practice, step by step: Asking the clinical question: A key step in evidence-based practice. American Journal of Nursing, 110(3), 58–61. doi:10.1097/01.NAJ.0000368959.11129.79
That is for Module 2 – # 137768 – unfortunately, none was used
Grant, M. J., & Booth, A. (2009). A typology of reviews: An analysis of 14 review types and associated methodologies. Health Information and Libraries Journal, 26, 91–108. doi:10.1111/j.1471-1842.2009.00848.x
Note: You will access this article from the Walden Library databases.
Hoare, Z., & Hoe, J. (2013). Understanding quantitative research: Part 2. Nursing Standard, 27(18), 48–55. doi:10.7748/ns2013.01.27.18.48.c9488
Note: You will access this article from the Walden Library databases.
Hoe, J., & Hoare, Z. (2012). Understanding quantitative research: Part 1. Nursing Standard, 27(15), 52–57. doi:10.7748/ns2012.12.27.15.52.c9485
Note: You will access this article from the Walden Library databases.