The Role of Technology in the Medication Use Process

1. The Role of Technology in the Medication Use Process Nursing Informatics

2. Introduction • Due to the numerous steps required in the care of patients, the healthcare industry is an inherently error-prone process that is fraught with opportunities for mistakes to occur • The healthcare industry must place safety as the number one priority and work diligently toward this goal.

3. Influences on the Adoption of Technology • A root cause analysis of errors revealed that there was no malpractice or egregious behavior, but that pharmacists and nurses simply interpreted an ambiguous handwritten order incorrectly.

4. Computerized Prescriber Order Entry (CPOE) • Factors that demonstrate the need for a shift in the system: • Accessing patient information spread across multiple organizations that may be unavailable • The structure of the patient’s record often makes it difficult to locate valuable information • Illegible handwritten entries by healthcare practitioners • For those patients with chronic or complex conditions, the records can increase to multiple volumes over many years. • Barriers that lead to ineffective communication of medication orders • Issues with illegible handwriting • Use of dangerous abbreviations and dose designations • Verbal and faxed orders

5. CPOE system = a system used for direct entry of one or more types of medical orders by a prescriber into a system that transmits those orders electronically to the appropriate department Potential enhancements of CPOE could offer: • Allow for prescribers to access records and enter orders from their office or home • Prescriber selectable standardized single orders or order sets • Implementation of organization-specific standing orders based on specific situations such as before or after procedures • Menu-driven organization-specific lists of medications on formulary • Passive feedback systems that present patient-specific data in an organized fashion such as: test results, charges, reference materials, progress notes • Active feedback systems to provide clinical decision making tools by providing specific assessments or recommendations through alerts and reminders or even therapeutic suggestions at the time the order is given

6. Advantages of CPOE systems: • Improve quality, patient outcomes, and safety by a variety of factors such as: • Increasing preventive health guideline compliance by exposing prescribers to reminder messages to provide preventive care by encouraging compliance with recommended guidelines • Identifying patients needing updated immunizations or vaccinations • Suggesting cancer screening and diagnosis reminders and prompts • Reductions in the variation in care to improve disease management by improving follow-up of newly diagnosed conditions by: • Reminder systems to improve patient management • Automating evidence-based protocols • Adhering to clinical guidelines • Providing screening instruments to help diagnosis disorders

7. Advantages of CPOE systems (continued): • Order systems can improve drug prescribing and administration by: • Improving antibiotic usage • Suggesting whether certain antibiotics or their dosages are appropriate for use • Medication refill compliance can be increased using reminder systems to increase adherence to therapies • Drug dosing could be improved, especially for those on medications whose dosing is based on laboratory results, such as heparin or warfarin, to maintain adequate anticoagulation control

8. Bar Code-Enabled Point-of-Care Technology BPOC can improve medication safety through the ff: • The system helps to verify that the right drug is being administer to the right patient at the right dose by the right route and at the right time

9. Steps in using the BPOC • On admission, patients are issued an individualized bar code wristband that uniquely identifies their identity. • When a patient is to receive a medication, nurses scans their bar coded employee identifier and the patient’s bar code wristband to confirm their identity. • Prior to medication administration, each bar coded package of medication to be administered at the bedside is scanned. • The system can then verify the dispensing authority of the nurse, confirm the patient’s identity, match the drug identity with their medication profile in the pharmacy information system, and electronically record the administration of the medication in an online MAR

10. Additional levels of functionality can include some of the ff features: • Increased accountability and capture of charges for items such as unit-stock medications • 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 • Monitoring the pharmacy and the nurse’s response to predetermined rules or standards in the rules engine such as alerts or reminders for the pharmacist or nurse • Reconciliation for pending or STAT orders • Capturing data for the purpose of retrospective analysis of aggregate data to monitor trends • Verifying blood transfusion and laboratory specimen collection identification

11. Negative effects include the following: • Nurses were sometimes caught “off guard” by the programmed automated actions • 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 • 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

12. Some of the following types of errors could also occur: Omissions. After the patient’s bar code armband and medication have been scanned, the dose is inadvertently dropped to the floor. Extra dose. An extra dose may be given when there are orders for the same drug to be administered by a different route. Wrong drug. In situations when the nurse administers a medication, which has not been labeled with a bar code. Wrong dose. In situations when the nurse has difficulty in scanning medication and proceeds to scan the medication twice. Unauthorized drug. An order to hold a medication unless a lab value is at a certain level Charting errors. Distinguish the indication for the administration of the medication Wrong dosage form. Certain drug shortages may force a pharmacy to dispense a different strength or concentration other than what is entered in the BPOC software

13. Automated Dispensing Cabinets • Is a computerized point-of-use medication-management system that is designed to replace or support the traditional unit-dose drug delivery system • Require staff to enter a unique logon and password to access the system using a touch screen monitor or by using finger print identification • Once logged into the system, the nurse can obtain patient-specific medications from drawers or bins that open after a drug is chosen from a pick list

14. The rationale behind the wide acceptance of this technology are the ff: • Improving pharmacy productivity. Streamlining of the dispensing system due to the reduced number of steps; also has the potential to reduce time needed to obtain missing medications • Improving nursing productivity. Time spent gathering or obtaining missing medications can be reduced • Reducing costs. Reduction in inventory and containment costs associated with expired medications • Improving charge capture. ADCs that are interfaced with the accounting department allow for the capture of all patient charges associated with administered medications • Enhancing patient quality and safety. ADCs that have built-in decision support systems that warn users on drug-drug interactions, drug-allergy interactions, drug-lab interactions, drug-drug duplications, and so forth

15. “Smart” Infusion Pump Delivery Systems • Infusion pumps are primarily used to deliver parenteral medications through IV or epidural lines • Incidents involving infusion pumps typically result from the unintentional free flow of solution. • Errors can also occur due to incorrect, inappropriate, or miscalculation of an order for the medication • Infusion pumps with dose calculation software, sometimes referred to as “smart pumps” could reduce medication errors, improve workflow, and provide a new source of data for continuous quality improvement by identifying and correcting pump-programming errors