The Role of Technology in Medication-Use Process Nursing Informatics

Introduction: The healthcare industry is an inherently error-prone process that is fraught with opportunities for mistakes to occur. Between 44,000 and 98,000 patients die each year in the United States from preventable error. These deaths were the results of practitioner interactions with “bad systems”.

Technology and Healthcare 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 But even as improving technologies have emerged allowing for seamless integration of information to occur , most organizations have shown little interests to incentive to incur the huge cost associated with replacing their nonintegrated computer system.

Influences on the Adoption of Technology According to a 1994 American Medical Association report, medication errors related to the misinterpretation of physicians’ prescription were the second most prevalent and expensive claim listed on malpractice cases filed over a 7-year period on 90,000 malpractice claims between 1985 and 1992. In outpatient setting , indecipherable or unclear orders resulted in more than 150 million telephone calls from pharmacists and nurses to prescribers requiring clarifications ,which not only is time-consuming for practitioners, but estimated to cost healthcare systems billions of dollars each year.

One of the first healthcare facilities to adopt bar code technology was the inspiration of a nurse at the Department of Veterans Affairs (VA) in Topeka , Kansas. Her insight resulted in a -74 % improvement in errors caused by wrong medication administration -57% improvement in errors caused by incorrect doses -91% improvement in wrong patients errors -92% improvement in time errors

Computer Prescriber Order Entry (CPOE) 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.

Barriers that lead to ineffective communication of medication orders: illegible handwriting -common cause of prescribing errors and patients injury and death Use of dangerous abbreviations Dose designations Verbal and faxed orders

Potential enhancements that a basic CPOE system can offer: Ambulatory care setting or both Allow 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 the 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 and progress notes or active feedback systems to provide clinical decision-making tools by providing specific assessments or recommendations through alerts and reminders

Advantages of CPOE: Increasing preventive health guidelines compliance by exposing to prescribers to reminder messages Identifying patients needing updated immunizations and vaccinations Suggesting cancer screening Improve drug prescribing and administration Medication refill compliance Drug dosing can be improve

CPOE would not only improve patient safety but also increase, efficiency, productivity, and cost effectiveness.

Bar Code-Enabled Point-of-Care Technology 38% of medication errors occur during the drug administration process Medication administration error occurred in almost 20% of doses of medications administered. One form of technology that will have a great impact on medication safety during the administration process BPOC technology. Bar code technology improve productivity and accuracy in the identification of products in variety of business settings ,such as supermarkets and department stores.

Yet, organizations in health industry embraced it. The reasons for these few numbers Cost of implementation Inadequate systems Lack of number of medications that are package with bar codes

The system helps to verify that the right drug is being administered to the right patient at the right dose by the right route and at the right time. 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 wristband to confirm their identity.

Additional levels of functionality can include some of the following features: Increased accountability and capture of charges for items such unit-stock medications Up-to-date drug reference information from online medication reference libraries. Customizable comments and alerts and reminders of important clinical actions need to be taken Monitoring the pharmacy and the nurse’s response to predetermined rules or standards in the rules engine such as alerts or reminders for the pharmacists and nurse Reconciliation for the pending or STAT orders. Capturing data for the purpose of retrospective analysis of aggregate data to monitor trends.

Negative effects include: Nurses were sometimes caught “off guard” by the actions taken by the BPOC software. 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 Nurses used strategies to increase efficiency that circumvented the intended use of BPOC.

Errors that had occurred: Omission Extra dose Wrong drug Wrong dose Unauthorized drug Charting errors Wrong dosage form

Bar Code-Enabled Point-of-Care Technology

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.

Automated Dispensing Cabinets

The rationales behind the wide acceptance of this technology are the following: Improving pharmacy productivity Improving nursing productivity Reducing costs Improving charge capture Enhancing patient quality and safety

Some documented unsafe practices with the use of these devices: Lack of pharmacy screening of medication order prior to administration Choosing of the wrong medication from an alphabetic pick list, High-alert medications placed, stored, and returned to ADC’s are problematic. Storage of medications with look-alike names and/or packaging The development of “workarounds”

“Smart” Infusion Pump Delivery Systems Infusion pumps are primarily used to deliver parenteral medications through IV or epidural lines and can be found in a variety of clinical settings ranging from acute-care and long-term care facilities, patient’s homes, and physician’s offices.

Incidents involving infusion pumps typically result from the unintentional free flow of solution (when the solution flows freely under the force of gravity ,without being controlled by the infusion pump). Due to incorrect, inappropriate, or miscalculation of an order for the medication.

“Smart pumps” are infusion pumps with dose calculation software. It could reduce medication errors, improve work flow, and provide a new source of data for continuous quality improvement by identifying pump-programming errors.

Implementation of Technology Many organizations have purchased various forms of automation, with little or inadequate planning and or preparation, which can lead to errors as well as the development of serious problems. It is vitally important to thoroughly plan for this process, and to remember your goal is to improve clinical processes, which can be facilitated by technology.

The multidisciplinary team will need to address the following issues: Outlining goals for the type of automation to be implemented Developing a wish list of desired features and determining which one ,given budgetary constraints, are practical. Investigating systems that are presently available. Analyzing the current workflow and determining what changes are needed. Identify the required capabilities and configuration of the new system. Development of an implementation plan.