1. The Health Roundtable Do Electronic Medication Systems Impact Patient Safety: What do the Frontline Clinicians Think? Debono, D. 1, Greenfield, D. 1, Black, D. 2, Braithwaite, J. 1 Innovation Poster Session HRT1215 – Innovation Awards Sydney 11 th and 12 th Oct 2012 1 Centre for Clinical Governance Research, Australian Institute of Health Innovation, University of New South Wales 2 Faculty of Health Sciences, University of Sydney 4-4d_HRT1215-Session_DEBONO_UNSW_NSW

2. The Health Roundtable KEY PROBLEM Medication Error  Key cause of iatrogenic harm  Exact measurement of the incidence of medication errors is difficult  17 percent of adverse events recorded in Australian hospitals 1  Estimated to occur at a rate of one per day per patient in US hospitals 2  Causes include:  illegibility of prescription and improper use of abbreviations  poor mathematical skills  insufficient knowledge of or access to information about medications  distractions and interruptions  nurse fatigue and stress 3  violations 4

3. The Health Roundtable PROPOSED SOLUTION Electronic Medication Management Systems (EMMS) Different types of EMMS  Electronic Medication Administration Record (EMAR)  Computerized Physician Order Entry (CPOE)  Bar Code Medication Administration Systems (BCMA)  Electronic Medication Management Assistant (EMMA) Aims  To standardise practice  Structure medication related tasks  Provide information support  Improve legibility of orders Research  Studies identify unintended consequences of the implementation of technology in practice 5 and resistance to technology implementation 6

4. The Health Roundtable AIMS To examine  What nurses perceive are barriers to using EMMS  Nurses’ perceptions of the effects of the EMMS on quality and safety This presentation reports on one component of a larger study that examines how nurses use EMMS in everyday practice

5. The Health Roundtable METHOD  The broader study utilised a qualitative multi-method approach employing document analysis, observation, process mapping, individual and focus group interviews  This presentation reports the preliminary results emerging from interviews and focus groups undertaken 2011-2012  Participants were nurses from six wards across two Sydney hospitals using two different types of EMMS  Data analysis is an ongoing iterative process using content and thematic analysis

6. The Health Roundtable EMERGING THEMES Nurses identified barriers when using the EMMS  The mobile computers (COWs) are cumbersome  Black spots in which there is limited or no connectivity  Crowding in medication rooms due to number of nurses and size of COWs  Battery life issues decreasing mobility of the COWs  Contradiction between policies (e.g. infectious rooms)  Workarounds were employed to circumvent some of the perceived barriers

7. The Health Roundtable EMERGING THEMES Nurses believed that EMMS had improved quality and safety Common to both types of EMMS  Improvement in legibility of orders  Point of care access to information resources e.g. MIMs, test results, instructions from pharmacists  Transparency and auditability  Visual notification when medications are late  Forcing functions

8. The Health Roundtable CONCLUSIONS  Nurses identified perceived barriers related to using EMMS and employed workarounds to circumvent some of these barriers  Nurses perceived that EMMS had improved quality and safety through improving information accessibility, legibility of orders and enhancing transparency and accountability  Other research provides quantitative support for nurses’ perceptions that EMMS improves quality and safety 7

9. The Health Roundtable ACKNOWLEDGEMENTS The exceptional nurses who so generously participated in this study The Information Systems teams who also generously gave their time and expertise The Funding Body: The NH&MRC Patient Safety Program Grant

10. The Health Roundtable REFERENCES 1. WILSON, R. M., RUNCIMAN, W. B., GIBBERD, R. W., HARRISON, B. T., NEWBY, L. & HAMILTON, J. D. (1995) The quality of Australian health care study. The Medical Journal of Australia, 163, 458-471. 2. THE INSTITUTE OF MEDICINE COMMITTEE ON IDENTIFYING AND PREVENTING MEDICATION ERRORS (2007) Preventing Medication Errors, Washington DC, The National Acadamies Press. 3. AMPT, A. & WESTBROOK, J. I. (2007) Measuring nurses' time in medication related tasks prior to the implementation of an electronic medication management system. Studies in Health Technology & Informatics, 130, 157-67. 4. FOGARTY, G. J. & MCKEON, C. M. (2006) Patient safety during medication administration: the influence of organizational and individual variables on unsafe work practices and medication errors. Ergonomics, 49, 444-56. 5. ASH, J. S., BERG, M. & COIERA, E. (2004) Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. Journal of the American Medical Informatics Association, 11, 104-12. 6. TIMMONS, S. (2003) Nurses resisting information technology. Nursing Inquiry, 10: 257–269. 7. WESTBROOK JI, RECKMANN M, et al. (2012) Effects of Two Commercial Electronic Prescribing Systems on Prescribing Error Rates in Hospital In-Patients: A Before and After Study. PLoS Med 9(1): e1001164. doi:10.1371/journal.pmed.1001164

11. The Health Roundtable Deborah Debono d.debono@unsw.edu.au