Chapter 12 The Role of Technology in the Medication-Use Process

1. Chapter 12The Role of Technology in the Medication-Use Process

2. Objectives: Define the benefits and limitations of automated dispensing cabinets in healthcare and its application to the medication process. Describe the factors tat will influence on the adoption of technology in healthcare. Recognize the benefits & limitations of bar code—enabled point-of-care (BPOC) technology as it relates to overall efforts to reduce medication errors including errors using these systems. Describe the challenges and rewards related to implementing a computerized prescriber order entry (CPOE) system. Recognize the value of and a methodology for assessing an organization’s readiness for implementing technology.

3. Introduction: Due to the numerous steps required in the care of nutrients, the healthcare industry is an inherently error-prone process that is fraught with opportunities for mistakes to occur, This concept was confirmed in the quoted 1999 Institute of Medicine (IOM) report, To Err is Human: Building a Safer Health System, where the authors extrapolated that bet. 44,000 and 88,000 patients die each year in the US from preventable medical error. These deaths were the results of practitioner interactions with “bad systems”.

4. One explicit recommendation emanating from the first of a series of IOM reports on healthcare is to improve the safety design of systems as is presently being employedin the other high-error prone industries such as aerospace and nuclear industry. • Technology and Healthcare • Until recently, the majority of technology acquisitions have consisted of basic stand-alone computer systems, which were primarily used for data input to increase each department’s efficiency with financial accountability measures.

5. These computers were generally installed in the pharmacology, radiology, and laboratory departments, and could also be found in the administration and business offices. • Influences on the Adoption of Technology • Consumers have become increasingly concerned that hospitals are less than safe following the numerous mass media reporting of medical mistakes, which have resulted in patient harm and deaths. In 1995, there were TV and newspaper accounts that reported the tragic death of a patient from a preventable

6. Adverse drug event (ADE) due to an inadvertent administration of a massive over dose of a chemotherapy agent over 4 days. This particular error became a watershed event for patients, practitioners, and healthcare organizations alike, not only because it occurred at the world renowned Dana Farber Cancer Institute, but also because it happened to the prestigious Boston Globe healthcare reporter Betsy Lehman. The root cause analysis of the error revealed that there was no malpractice or egregious behavior,

7. but that excellent, conscientious and caring pharmacists & nurses simply interpreted an ambiguous handwritten chemotherapy order incorrectly. In retrospect, had technology been available, the physician would have entered the medication into a CPOE system and this heartbreaking error would not have happened. • Medication errors related to misinterpretation of physicians’ prescriptions - were the 2nd most prevalent and expensive claim listed on malpractice cases over a 7-year period on 90,000 malpractices bet. 1985 & 1992, accdg. To 1994 (AMA)

8. Computer Prescriber Order Entry(CPOE) Healthcare practitioners still communicate information in the “old fashioned way”. It has been estimated that handwritten prescriptions are used 99% of the time to communicate orders. There are many factors that demonstrate the need for a shift fromm a traditional paper-based form that relies on the unaided mind to automated order entry, record keeping, and clinical care.

9. These factors include accessing patient information spread across multiple organizations that may be unavailable, especially in large organizations &, therefore, medical care should be provided without pertinent patient information. The structure of the patient’s record often makes it difficult to locate valuable information, illegible handwritten entries by healthcare practitioners and for those patients with chronic or complex conditions, the records increase to multiple volumes over many years.

10. These problems result in a variety of communication breakdowns when providing healthcare to patients from the publication of services, delays in treatment , increased length of stay, & increased risk of medical errors. Additionally, human memory-based medicine can be inaccurate or not recalled.

11. There are also many barriers that lead to ineffective communication of medication order that include: • Issues with illegible handwriting • Use of dangerous abbreviations and dose designations • Verbal and faxed orders. • As a result of poor handwriting, 50% of all written physician orders require extra time to interpret. • 16% of physicians have illegible handwriting (Cohen, 1999)

12. 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. • The use of CPOE system has the potential to alleviate many of these problems. • CPOE cab be defined as 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. (AHA, 2000)

13. Other features of (CPOE): • 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 ; and • Passive feedback systems that present patient-specific data in an organized fashion such as test results, charges, reference materials & progress notes, or active feedback systems.

14. CPOE systems offer many other advantages over the traditional paper-based system. They can improve quality, patient outcomes, and safety by a variety of factors such as: • Increasing preventive health guideline compliance with recommended guidelines • Identifying patients needing updated immunizations or vaccinations, and • Suggesting cancer screening & diagnosis reminders & prompts.

15. Other advantages include: • Reductions in the variation in care to improve disease management by 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.

16. Bar Code-Enabled Point-of-Care Technology • Nurses play a vital role in the medication-use process, ranging from their involvement in the communication of medication orders to the administration of medications. As nurses know well, the administration of medications can be a labor-intensive & error-prone process.

17. One study showed that 38% of medication errors occur during the drug administration process (leape et al,1995). • Few organizations in the healthcare industry embraced this valuable technology as a medium to enhance patient safety. In fact, the results of the ISMP Medication Safety Self-Assessment, , 1,435 hospitals showed tat only: • 43% of hospitals had even discussed the possibility of bar code drug administration • 2.5% used this technology in some areas of the hospital • Less than 1% had fully implemented it throughout the organization

18. The use of an online MAR is likely to be more accurate than traditional handwritten MARs. Furthermore, the bar code scanner can enable nurses to have greater accuracy in recording the timing of medication administration, as the computer generates an actual “real-time” of medication administration. Additional levels of functionality can include some of the following features: • Increased accountability & capture of charges for items such as unit-stock medications. • Up-to-date drug reference information from online medication reference libraries.

19. Customizable comments or alerts & reminders of important clinical actions that need to be taken when administering certain medications. • Monitoring the pharmacy & the nurse’s response to predetermined rules or standards in the rules engine. • 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.

20. One study noted 5 significant negative effects that occurred during the implementation of a BPOC system at VA hospitals that might create new paths to ADEs. Negative effects include the ff: • 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.

21. 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 in a few minutes late. • Nurses used strategies to increase efficiency that circumvented the intended use of BPOC.