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Pouliot et al
up-front ordering module only and did not flag high-risk
medications for the entirety of epidural therapy. Therefore,
an opportunity existed for a different provider who was
unfamiliar with the restrictions associated with epidural
management to order one of the inappropriate medications
without any warning or instruction. To address this concern,
the informatics team developed a secondary "exit-check" to
notify other prescribers of the presence of an epidural infusion
if they tried to order a high-risk medication after an epidural
was placed. This exit-check required the prescriber to fully
acknowledge the concomitant ordering of a high-risk
medication in patients with an active order for epidural
therapy.
With the full implementation of the decision support module, our postimplementation group showed a decrease,
although not statistically significant, in the overall instances
of inappropriate medication administration. Of note, the postimplementation group showed an elimination of improper
enoxaparin administered versus the preimplementation group.
Limitations of this study are that it was a retrospective
chart review at a single academic medical center over a very
short period of time. Our study was underpowered based on
a post hoc power analysis utilizing sample sizes in each
group and the effect size found in the primary outcome (and
assuming alpha = 0.05). Although the study did not have
adequate power on a post hoc analysis, our data did show a
significant reduction in inappropriate enoxaparin prescribing.
The study authors felt that identifying a period of time around
the implementation of the epidural module would be most
beneficial to control for confounders and changes in practice
not relating to the research question. This likely limited the
number of patients to be evaluated and resulted in not meeting
power. In addition, limitations to the module itself and the
inability to screen for medications administered prior to
admission could have affected the results of the study. The
type and dose of epidural administration was also not
collected and could have affected the secondary outcomes
rates. One of the major challenges with high-risk medications is the difficulty in screening for these medications prior
to admission. Some computerized medication records now
incorporate a home medication list in the screening tool;
however, this assumes an accurate medication reconciliation
was obtained, which is a difficult assumption in many practice
settings. However, the results seen in this study can be
clinically applicable given the nature of the outcomes and
reduction in medication error risk. The most significant
limitation of this study was the acceptance and functionality
of the ordering module itself, and further examination of its
functionality is needed to optimize this tool.

Conclusion
In conclusion, a computerized clinical decision support tool
for continuous regional epidural anesthesia therapy that was
incorporated into the CPOE system at Vanderbilt University

Medical Center was not associated with a significant difference
in the overall incidence of inappropriate medication administration or therapy-related complications, but was associated
with the reduction in the administration of enoxaparin and
eliminated all inappropriate anticoagulant administration.
There was also a nonsignificant reduction in the postimplementation group in rapid response events, naloxone administration, and improper medication use overall. Further study
would be required with a larger sample size to determine the
significant differences of these rare events. While there are
many possible reasons for these findings, the results underscore the importance of proper use of clinical decision support
with additional research about how such tools are utilized in
practice. This study also shows the importance of testing interventions such as decision support to ensure that efforts to
implement such tools are resulting in better patient care and
positive outcomes. Future study on high-risk medication
screening in the outpatient setting prior to admission would
be beneficial as computerized decision support and synchronization of medical records systems continue to improve.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

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