Keywords: Quality improvement, medication safety, electronic decision support

Background: Acetaminophen is widely used as part of a multimodal pain strategy in perioperative settings for its ability to alleviate pain and minimize opioid requirements. For most patients, literature supports a safe therapeutic limit of up to 1,000 mg every 6 hours, not exceeding 3,000 mg daily. In older patients or those at high risk of hepatotoxicity the limit is 2,000 mg daily. Inadvertent repeat dosing from multiple providers poses a significant risk of hepatotoxicity. Factors contributing to repeat dosing errors include administration in multiple settings, inadequate communication among providers, and poor medication reconciliation. This study evaluates electronic decision making support as part of a quality improvement project to decrease acetaminophen repeat dosing errors.

Objective: This quality improvement project evaluates the impact of educational and electronic decision support tools on reducing inadvertent acetaminophen repeat dosing errors in perioperative settings.

Methods: This is a retrospective study of repeat acetaminophen dosing errors in adults (18 years old or greater) undergoing anesthetic care with the Department of Anesthesiology and Perioperative Medicine at UCLA from January 2019-January 2025. Electronic adverse reporting system (eARS) reports of medication errors were abstracted and manually identified for repeat acetaminophen dosing errors, which was defined as either (1) administration preoperatively followed by intraoperative administration prior to 6 hours, or (2) administration within 6 hours of the last intraoperative dose. Initial interventions to prevent repeat acetaminophen dosing errors were educational. These were followed by electronic decision support tools including an automated dispenser cabinet warning and medication story board and acetaminophen warning on the electronic record.

Results: Out of 193 medication errors, 11 cases of inadvertent acetaminophen redosing were identified. Four cases occurred in 2021-2023. The remainder of the cases (7) were in 2024. Three cases occurred in Dec 2023 and Jan 2024, while another two occurred in May 2024. Three occurred in July-August 2024 and none occurred from August 2024-January 2025. 9/11 (81.8%) cases were in outpatient settings. 64% of patients were female and the mean age involved was 56 years. Data analysis of this cohort of affected patients and characteristics of repeat dosing errors is ongoing. Out of the cases in 2024, two cases occurred prior to educational intervention and 5 occurred afterwards. Prior to full electronic decision support implementation, 5 cases occurred, and two occurred afterwards. Notably, neither of these two cases had a recorded acetaminophen warning alert, despite meeting the criteria for one.

Conclusions: The introduction of electronic medication alerts, warning banners, and automated dispensing cabinet warnings was associated with a reduction in inadvertent acetaminophen redosing events. Gaps in alert activation for select cases may suggest the need for further refinement of the system.