Role of Technology in Medication Use Process

ROLE OF TECHNOLOGY IN MEDICATION USE PROCESS

Charisse Hazel G. De Leon, RN

IMPORTANT FACTS: In fact, less than 10% of health care organizations

have yet to incorporate any type of medication safety technology indicating that they have allocated their limited financial and human resources in other directions.

1995 –television and newspaper accounts that reported the tragic death of a patient from a preventable adverse drug event (ADE) due to an inadvertent administration of a massive overdose of a chemotherapy agent over 4 days at the Dana Farber Cancer Institute

How do we solve the problems with regard to medication usage

and administration?

Solutions to the problem:IT INNOVATIONS IN MEDICATION USE

PROCESS • Computerized Prescriber Order Entry

(CPOE)• Bar Code-enabled point-of-care

technology• Automated Dispensing Cabinets• Smart Infusion Pump Delivery Systems

The Spoonful of Sugar: medicine management in NHS hospitals (Audit Commission 2001) report concluded:

• Complications arising from medicines treatment are the most common cause of adverse events in hospital patients.

• Errors may occur from the initial decision to prescribe to the final administration of the medicine, and these include choice of the wrong medicine, dose, route, form, and frequency.

• Prescription sheets themselves may also be temporarily unavailable or lost.

• In the outpatient setting that indecipherable or unclear orders resulted in more than 150 million telephone calls from pharmacists and nurses to prescribers requiring clarification.

• Handwritten prescriptions are used 99% of the time to communicate orders.

• Studies have shown that as a result of poor handwriting, 50% of all written physician orders require extra time to interpret.

• Illegible handwriting on medication orders has been shown to be a common cause of prescribing errors and patient injury and death have actually resulted from such errors

COMPUTERIZED PRESCRIBER ORDER ENTRY (CPOE)

The Leapfrog Project advocated the use of CPOE technology to prevent errors.

Benefits:

• Increased accessibility to patient information across multiple organizations

• Standardization of patient’s record, minimizing illegible handwritten entries

• Improvement of communication among health care providers and patients

• Improvement of patient outcomes and safety - increasing preventive health guideline compliance by exposing prescribers to reminder messages

Benefits:

Reduction in the variation of care to improve disease management- improving follow-up of newly diagnosed conditions, reminder systems to improve patient management, automating evidence-based protocols, adhering to clinical guidelines, or providing screening instruments to help diagnosis disorders

Improvement of drug prescription and administration - improving antibiotic usage, suggesting whether certain antibiotics or their dosages are appropriate for use

Benefits:• Medication refill compliance can be increased

- Using reminder system to increase adherence to therapies

• Improved drug dosaging• Reduction in ADEs• *Serious medication errors were reduced by

55% and preventable ADEs were reduced by 17% (Bates et al, 1998). Non-missed-dose medication errors fell from 142/1,000 patient days to 26.6/1,000 patient days.

CPOE:Underlying issues

• High implementation costs• - Increased need for a fiber-optic backbone

network; time, space, and manpower to provide adequate staff education and development; and workstations and high-speed internet access

• Integration of ‘legacy’ systems of the organization in the implementation of CPOE

• Existence of the possibilities of medication errors

CPOE:Underlying issues

• The activation of warning and alerts during use of CPOE

• - Vendors do not include them in the package or not programmed for use by organizations

• Complexity of the system and absence of interface between laboratory system and medication order entry system

While about half of the ordering, transcribing, and dispensing errors were intercepted by the nurse before the medication error reached the patient, almost none of the errors at the medication administration stage were caught.

Forty three (43%) of hospitals had even discussed the possibility of bar code drug administration. Two and a half percent (2.5%) used this technology in some areas of the hospital. Less than one percent had fully implemented it throughout the organization (Cohen and Smetzer, 2001).

Bar Code-enabled point-of-care technology

The Department of Veterans Affairs (VA) is one of the first healthcare facilities to fully adopt bar code technology.

On admission, patients are issued an individualized bar code wristband that uniquely identifies their identity, scanned prior to drug administration, verifies the nurse, patient, and the medication, and electronically record the administration of the medication in an online MAR

• JCAHO has stated that a bar code with two unique, patient-specific identifiers will provide healthcare organizations a system that complies with the 2004 National Patient Safety Goal

• During the introduction of the BPOC, reported medication error rates declined from 0.02% per dose administered to 0.0025% (Johnson et al, 2002).

• Aim: Improve medication safety through several functionalities

FEATURES:

• Increased accountability and capture of charges for items

• Up-to-date drug reference information from online medication reference libraries

• Customizable comments or alerts and reminders of important clinical actions that need to be taken when administering certain medications

FEATURES:

• Monitoring the pharmacy and the nurse’s response to predetermined rules or standards in the rules engine

• Reconciliation for pending or STAT orders• Capturing data for retrospective analysis of

aggregate data to monitor trends• Verifying blood transfusion and laboratory

specimen collection

Bpoc:underlying issues

• Nurses were sometimes caught ‘off guard’ by the programmed automated actions taken by the BPOC software

• The BPOC seemed to inhibit the coordination of patient information between prescribers and nurses when compared to a traditional paper-based system.

• Nurses found it more difficult to deviate from the routine medication administration sequence with the BPOC system.

Bpoc:underlying issues

• Nurses felt that their main priority was the timeliness of medication administration because BPOC required nurses to type in an explanation when medications were given even a few minutes late.

• Nurses used strategies to increase efficiency that circumvented the intended use of BPOC.

• Pharmaceutical industry’s unwillingness to adopt a universal bar code standard

Bpoc:underlying issues

• Extended lag time between the launch of new medications and their availability in unit-dose packaging, as well as non-bar coded medications

• Possibility of errors:Wrong drugCharting errorsWrong doseUnauthorized drugWrong dosage form

Automated Dispensing Cabinets

An ASHP survey showed that 58% of hospitals employed technology that totally redesigned the medication-management system from the traditional unit-dose dispensing system to a decentralized system utilizing ADC on patient care units.

A computerized point-of-use medication-management system that is designed to replace or support the traditional unit-dose drug delivery system; it requires the staff a unique logon and password to access the system using a touch screen monitor or by using finger print identification

Benefits:

• Improving pharmacy productivity- reduce number of steps from filling medication bins to filling a centralized station; reduce time needed to obtain missing medications

• Improving nursing productivity- reduce time in obtaining missing medications and newly ordered medications

• Reducing costs- reduce inventory and containment costs associated with expired medications

Benefits:

• Improving charge capture- allow capture of all patient charges associated with administered medications

• Enhancing patient quality and safety- built-in decision support systems that warn users on drug-drug interactions, drug-allergy interactions, drug-lab interactions, drug-drug duplications and so forth.

• Tracking the storage, dispensing, and use of controlled substances

ADC:UNDERLYING ISSUES

Lack of pharmacy screening of medication order prior to administration

Choosing of the wrong medication from an alphabetic pick list

Use of high-alert medications placed, stored, and returned to ADCs- patient injury or death may arise if there is absence of independent double check from nurse and from the pharmacy*High alert medications – medications that, when involved in medication errors, have a high risk of injury or death

ADC:UNDERLYING ISSUES

• Storage of medications with look-alike names and/or packaging

• - due to confirmation bias• Development of nurse’s ‘workarounds’• -when the device does not respond as

expected, nurses will find various ways of working around the system to obtain medications

Smart Infusion Pump Delivery Systems

• Infusion pumps with dosage-calculation software used in the administration of parenteral medications thru IV or epidural lines; medications are administered based on a calculation of a volume to be infused per hour of delivery

• Aim: Reduce medication errors, improve workflow, and provide a new source of data for continuous quality improvement

BENEFITS:

• Maximum flexibility, increasing application to different areas of the hospital

• Applicability of the infusion pump regardless of patient’s condition, age, and gender

• Improvement of patient care, minimizing human memory created errors

BENEFITS:

Improvement of drug administration- Thru comprehensive libraries of drugs, usual concentrations, dosing units, and dose limits, warnings to exceeded dosage limits, and configurable settings by patient type or location

Verification of the programming of medication delivery- Thru prompts and alerts, and setting dosage limits

Eased access to transaction data from the infusion device, leading to improved patient quality and improved clinical decision-making

Smart infusion pumps:underlying issues

• Infusion-device programming errors• - single wrong entry or button pressed• - nurse’s wrong programming of the dosage • High implementation costs