1. NPR REPORTS, RULES AND MEDICATION SAFETYby
Steven Botwinski, R.Ph.,
Yvonne Kimura, Pharm.D.
Hao Luu, Programmer
Bruce Matthias, R.Ph.
The IN Group, Inc.
February 18, 2009

2. Goals: Demonstrate how rules, NPR reports and
customer defined screens can be used to aid
in regulatory compliance
Demonstrate how NPR reports can be used to
increase the efficiency of clinical monitoring

3. JCAHO National Patient Safety Goal 2008
Goal 3E: Reduce the likelihood of patient harm associated with the use of anticoagulation therapy.

4. Anticoagulation monitoring
Anticoagulation protocol
Baseline INR required (order entry-
pharmacist)
Administration current INR (eMAR-nurse)
Clinical progress (daily rounds-pharmacist)
Performance measures (pharmacy
director)

5. Anticoagulation monitoring - Order entry
Baseline INR required prior to starting warfarin
Pharmacy rule for pop up screen to warn the
pharmacist that no baseline INR has been
ordered within 24 hours

7. Anticoagulation monitoring - Medication administration
The medication should not be administered if
the most recent (within 24 hours) INR is
outside the acceptable range.
eMAR rule to warn the nurse that the INR is
outside the safe range
Display INR value
Require action and response

11. Anticoagulation monitoring - Clinical monitoring
Pharmacist monitoring patient progress
Patient response to therapy
Potential drug interactions
Monitoring all anticoagulants
Use scheduled NPR report
Screen patients
Pertinent data (lab trends, other meds)

12. Anticoagulation monitoring - Performance measures
Administrative report for all anticoagulant use
Degree of compliance
Institutional performance trends
Detail for follow-up as needed
Use NPR report
Run for specific date range
Use data from PHA, LAB, NUR, OE
Include heparin, enoxaparin, argatroban
and warfarin) for baseline labs and
changing renal function if applicable

14. Black Box Warnings Types of Black Box Warnings
Intervention required at order entry
Informational for nursing
Intervention required during therapy
Can be a combination of the above

15. Black Box Warnings - Intervention at order entry
PHA order entry
Rule with pop-up screen
Data used from other modules to prevent over flagging (example: female, childbearing age, pregnant? Yes, No, or information missing)

20. Black Box Warnings - Informational for nursing
Information in entirety can be placed in special instructions to be viewed by nurse in eMAR
Advantage: no need for external printer or separate routine
Disadvantage: requires extra keystroke to seen entire text or RN may not notice it is there

24. Black Box Warnings - Intervention at administration
Information in entirety can be placed in Rx comments to be viewed by nurse in eMAR
Full text seen on Acknowledge
Drawback: requres extra key stroke to view full text on first screen of eMAR

28. Black Box Warnings - Intervention at administration
Information in entirety can be placed in admin criteria to be viewed by nurse in eMAR
Will pop-up automatically for viewing in eMAR with each administration and on acknowledge (example: use for quinolones)
Other potential uses: look-alike, sound-alike

35. Vaccine Administration

36. Vaccine Administration
Vaccine administration requirements
Record lot number and expiration
Provide patient with current vaccine
information sheet (VIS)

37. Vaccine Administration
Create a CDS for eMAR
Administration query to record lot number
and expiration
Prompt “Vaccine Information Sheet Given?
Automatic launch to CDC website to obtain
current VIS (

42. Neonatal Dose Verification and Documentation Witness
Dose verification and preparation verification
by a second nurse
Alleviate need to create a separate pediatric
drug formulary
Audit trail for policy adherence / accountability

43. Neonatal Dose Verification and Documentation Witness
eMAR cosignature as part of the prescription audit trail is a great solution…. BUT
eMAR cosignature has been an all or none phenomena once set up in the drug dictionary…. UNITIL NOW

44. Neonatal Dose Verification and Documentation Witness
Set up eMAR rule
If patient age is <30 days, require a
cosignature for verification of dose and
preparation
Include the cosignature as part of the Rx
audit trail
Attach the eMAR rule at the global
Customer Defined Parameter level