Reducing prescribing errors in hospitalized children on the ketogenic diet

ABSTRACT Background Children on ketogenic diet must limit carbohydrate intake to maintain ketosis and reduce seizure burden. Ketogenic diet patients are vulnerable to harm in the hospital setting where carbohydrate-containing medications are commonly prescribed. We developed clinical decision support (CDS) to reduce inappropriate prescription of carbohydrate-containing medications in hospitalized children on ketogenic diet. Methods A CDS alert was developed through formative and summative usability testing. The alert warned prescribers when they entered an order for a carbohydrate-containing medication in ketogenic diet patients. The alert was implemented using a quasi-experimental design with sequential crossover from control to intervention at two tertiary care pediatric hospitals within a single health system. The primary outcome was carbohydrate-containing medication orders per patient-day. Results During the study period, there were 280 ketogenic diet patient admissions totaling 1219 patient-days. The carbohydrate-containing medication order rate declined from 0.69 to 0.35 orders per patient-day (absolute rate reduction 0.34, 95% CI 0.25-0.43), corresponding to 256 inappropriate orders prevented. The alert fired 398 times and was accepted (i.e., the order was removed) 227 times for an overall acceptance rate of 57%. Conclusions Implementation of a CDS alert at order entry resulted in a sustained reduction in carbohydrate-containing medication orders for hospitalized ketogenic diet patients without an increase in alert burden. CDS developed with user-centered design principles can improve patient safety for children on ketogenic diet by influencing prescriber behavior.