Potential Effects

1. Potential Effects Medication Safety When Adding EMR

2. Last year • Inpatient Unit converted from paper charts to electronic documentation • Pharmacy entering orders electronically • Phased approach • Bedside Medication Verification (BMV) not planned until August 2012, so nursing using printed MAR

3. Complaints • Complaints surfacing about variance between paper MAR and orders during chart checks • Nurses felt that pharmacists were making errors • Pharmacists felt nursing complaints were unfounded • Chart checks took a long time • Nurses were handwriting corrections

4. First Steps • Created a reporting mechanism • Encouraged reporting • Encouraged reporting • Encouraged reporting • Encouraged reporting • Encouraged reporting

5. Action Steps • Reviewed each entry with pharmacy and nursing • Grouped similar items • Started with low-hanging fruit • Looked at processes and re-education • Continued each month

6. Looking at the Problem 63 discrepancies in the first month of measurement

7. Looking at the Problem

8. PfP Metrics Note: ADE increase in May due to inclusion of nausea or itching

9. Changing Landscape • eMAR and Bedside Medication Verification • Scanning problems • Barcode issues • Training and training and training • Printed MAR versus eMAR

10. Current and Future • Fewer discrepancies or less reporting? • User error or system error?