Hospital Pharmacy - June 2018 - 170

741392
research-article2017

HPXXXX10.1177/0018578717741392Hospital PharmacyPouliot et al

Article

The Role of Computerized Clinical
Decision Support in Reducing
Inappropriate Medication Administration
During Epidural Therapy

Hospital Pharmacy
2018, Vol. 53(3) 170-176
© The Author(s) 2017
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https://doi.org/10.1177/0018578717741392
DOI: 10.1177/0018578717741392
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Jonathon D. Pouliot1, Erin B. Neal2, Bob L. Lobo2,
Fred Hargrove2, and Rajnish K. Gupta2

Abstract
Background: The use of epidural anesthesia has been shown to improve outcomes in the postoperative setting. To minimize
risk of complications, avoiding certain medications with epidural anesthesia is advised. Objective: This study sought to
determine the role of a computerized clinical decision support module implemented into the computerized physician order
entry (CPOE) system on the incidence of administration of medications known to increase complications with epidural
anesthesia. Methods: This study was a retrospective cohort chart review in adult patients receiving epidural anesthesia
for at least 1 day. Patients were identified retrospectively and divided into 2 cohorts, those receiving an epidural 3 months
prior to initiation of the module and those receiving an epidural 3 months following implementation. The primary end point
was incidence of inappropriate medication administration before and after implementation. Complications of therapy were
collected as secondary end points. Results: There was a reduction in the incidence of inappropriate medication administration
in the postimplementation group versus the preimplementation group (6.3% vs 12.8%) although statistical significance was
not achieved. In addition, the incidence of enoxaparin administration was significantly lower postimplementation than the
preimplementation (0% vs 3.9%). There were no significant differences in other complications of therapy. Conclusions: This
study demonstrated that application of decision support for this high-risk procedural population was able to eliminate the
incidence of the most common inappropriate medication for epidural analgesia, enoxaparin. A reduction in incidence of other
inappropriate medications was also observed; however, statistical significance was not reached. The use of computerized
clinical decision support can be a powerful tool in reducing or ameliorating medication errors, and further study will be
required to determine the most appropriate and effective implementation strategies.
Keywords
anesthetics, pain management, information systems and technology, medication errors, medication safety

Background
The use of epidural anesthesia has been shown to improve
morbidity and mortality outcomes in the postoperative
setting.1,2 However, despite the advantages to epidural
analgesia, there are several complications that health care
providers must be cognizant of when initiating, maintaining,
and discontinuing epidural therapy.
Complications can be grouped into 2 main categories:
complications related to neuraxial administration of medications
and complications resulting from bleeding at the epidural
catheter site.3-7 Complications due to neuraxial administration
of opioids, anesthetics, and possibly clonidine can include
respiratory depression, hypotension, altered mental status,
and somnolence among others and are usually monitored and
managed by adjusting doses or rates and in severe cases

using reversal agents such as naloxone.3,4 Of bleeding
complications with this type of analgesic technique, epidural
hematoma is the most concerning as it can result in paraplegia
and possibly death.5-7 While bleeding risk is very rare with
specific risk of intracranial hematoma reported as 0.07 events
in 10 000 cases,4 the concomitant administration of anticoagulants, antiplatelets, and thrombolytics has the potential
to significantly increase this risk.5
1

Lipscomb University College of Pharmacy and Health Sciences, Nashville,
TN, USA
2
Vanderbilt University Medical Center, Nashville, TN, USA
Corresponding Author:
Jonathon D. Pouliot, College of Pharmacy & Health Sciences, Lipscomb
University, 1 University Park Drive, Nashville, TN 37204-3951, USA.
Email: jdpouliot@lipscomb.edu
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