VIP Call Girl Sector 25 Gurgaon Just Call Me 9899900591
Electronic prescribing system medication errors: Identification, classification and mitigation
1. Learning’s from an Ad Hoc Evaluation of the
Taranaki DHB (TDHB)
ELECTRONIC PRESCRIBING PILOT
2. 1/3 National Pilot Sites
TDHB INTEGRATION focus
MedChart v6.3 with
limited decision support
1 way interface ePharmacy
+ ePharmacy
1 way interface with Pyxis
+ Pyxis
+ eMedRec
Background
3. Electronic Prescribing
“not just a technology –it is a complex design / redesign
of clinical processes that integrates technology to
optimise physician ordering of medications. By its nature it
reconfigures hospital operations and workflow and
affects virtually all operations”
What we knew…
4. End User perspective
24/7 multi-user access from anywhere
100% clear, complete prescriptions
Decision support Allergies, Duplication, Interactions, Dose Ranges, Rules
Medication Information Interaction checker, Datasheets, TDHB protocols
Integration of tasks Administration, Pharmacist Review
Integration of systems Allergies, Dispensary, Laboratory
What we knew…
5. IF DONE WELL …improves outcomes
MedChart v5.1 (St Vincent’s, Sydney)
Reduces error rates by 60%
Compared to 5-10% for National Drug Chart
Type
procedural errors
clinical errors
serious errors
Remaining 40% errors
15% errors introduced by the system ” eg Wrong strength / Timing
= FOCUS OF THIS PRESENTATION .
What we knew…
6. IF DONE WELL…improves outcomes
Workflow
No changes in time spent
in direct care
on medication related tasks
Prescribers spent time with doctors & patients
Nurses spent time with doctors
What we knew…
7. BUT its NOT a magic bullet
Can contribute to errors
Unintended consequences expected 1
Increases mortality if poorly implemented 2
Environment matters more than the system 3
1. Campbell E et al. Types of unintended consequences related to CPOE. JAMIA 2006; 13(5):547-556.
2. Han YY et al. Unexpected increased mortality after implementation of a commercially sold computerised physician order entry system.
Paediatrics 2005; 116(6):1506-12
3. Metzger J et al. Mixed results in the safety performance of computerised physician order entry. Health Affairs 2010; 4: 655-663
What we knew…
8. Also will …
NOT … fit everything on one page
NOT … stop scripts being “CLEARLY” wrong
NOT … stop you doing something stupid
NOT … make clinical decisions for you
NOT … replace communication with staff
What we knew…
9. Complex
CONTEXT is everything
HOW is as important as WHAT
What we knew…
10. What we knew…
…the VALUE PROPOSITION…
...Will need to learn to do things differently,
but there will be benefits in return…
11. In the TDHB context
Implement safely?
What were the unintended consequences?
What were the new types of errors ?
How could we mitigate the risks associated with these?
What we wanted to know…
12. Use existing data where-ever possible
Extensive baseline
Monitored at 4, 8 & 12 months
Quality improvement approach
Started with subset of Pilot ward to understand TDHB
context & validate / refine workarounds
< 4 months 17 patients 3 prescribers
≥ 4 months 25 patients 48 prescribers
Pro-actively engage end-users & promote feedback
Approach
15. Each Audit
Subset of results
Strategies used
Training / Education
Configuration
Workflow
Enhancement requests
Lessons learned
Outline
16. Compliance with TDHB Prescribing Guidelines 59 parameters
Completeness
Legibility
Legality
24hr snapshot n=2413 prescriptions
All prescriptions vs Pilot ward 2012
Pilot ward paper vs electronic 2012
electronic scripts 8.4% All & 32% Ward
Prescribing Audit
17. Legibility to 100%
Legality to 100% - except for dose
Completeness - Patient
flagging of supplementary charts
allergy documentation
re-chart dates
numbering of multiple charts
Prescribing Audit
18. Completeness – Drug
ceasing
modifications
minimum dose intervals for PRNs
compliance with generic prescribing
use of review/stop dates
dose range guidance
use of indication
Prescribing Audit
19. Actions
Enhancement requests Vendor / NeMP
Dose forms that require dose creams & ointments
Unapproved abbreviations mcg & IU
Review date function medicine not drop off chart
Lessons Learned
Small changes for 100% legality (& legibility)
Completeness improved in most instances
Prescribing Audit
20. 2 years pre & 1 year post n=1119
Pilot ward 6.6% All errors (n=78)
2 year pre 65% (n= 48)
1 year post 35% (n= 26)
Sub-analysis 4, 8 & 12 months
Place in Medication Use process
Type of error
Factors involved
Medication Safety Database Grade 1-5
21. 88% events involved MedChart
after 4 mths when pilot expanded
end user reporting by 12mths
Place in Medication Use process
Prescribing 39% (Transcribing 56%)
Administration 57%
Pharmacy 4%
Medication Safety Database
0
5
10
15
20
25
4mth 8mth 12mth
Period
REPORTED ERRORS
24. Withholding
New workflow
= not medication specific + 2 steps required + poor visibility
3 different workarounds trialled…
1. Medicine charted + Administration Alert
2. Medicine ceased + Prescribing Alert
3. Medicine Blocked + Prescribing Alert
Medication Safety Database
25. Withholding
1. Medicine charted + Administration Alert
Alert after patient selection, NOT at Administration
Added in QUALIFIER (displayed at point of Admin)
Added in Prescribing ALERT
… worked well with 3 prescribers but with 48 infrequent prescribers …
Medication Safety Database
26. Withholding
2. Medicine ceased + Prescribing Alert
… no reported issues but risk of medicines not being restarted …
3. Medicine blocked + Prescribing Alert
Remains charted but unable to be administered
Flagged on “Overdue Meds” screen (Nurse)
…Not automatically flagged on “Patient Summary” screen (Dr rounds)…
Medication Safety Database
27. Withholding
Actions
Training scenarios
Education Campaign
Enhancement Vendor / NeMP
Preventing roll out to surgery
Medication Safety Database
28. Wrong start date/time Transcribing
New workflow = Defaults to start medicine at NEXT available
dosing time
Medication Safety Database
29. Wrong start date/time
Action
Training Dr scenarios
Educate
Nurses about doctor workflow, especially defaults
Pharmacists focus on timing issues for new admissions
Medication Safety Database
30. Nurse education about prescriber defaults
Medication Safety Database
31. Strength / Dose mismatch
New workflow = Prescription includes strength
Medication Safety Database
32. Strength / Dose mismatch
Action
Training scenarios
Education
Doctors about strength /dose display in Admin screens
Campaign for recommended workflows
Medication Safety Database
33. Strength / Dose mismatch
Action
Nurse Workflow Education
Select medicines from Pyxis in “Administration” screen
CHECK medicines in “Confirmation” screen (reads like a sentence)
Medication Safety Database
34. Strength / Dose mismatch
Action
Doctor Workflow Education
If dose expected to change a lot
chart without strength
For other dose changes, where-ever possible
“cease” medicine and start new strength
(rather than editing old strength)
Medication Safety Database
35. Strength / Dose mismatch
Action
Enhancement Vendor / NeMP
Delivered 8.1.1
Prompt Doctor on editing dose to select more appropriate strength if exists
Removed strength from left hand side of Nurse “Administration” screen
Medication Safety Database
36. Not checking Administration History
New workflow =
Separate screen & extra mouse clicks
Not visible at time of Administration
Action
Simplification of 7 steps into 3
= llergies, lerts, dmin History (in DRUG ROOM) +
= Selection, Retrieval, Checking (in DRUG ROOM) +
= (at BEDSIDE)
Education Campaign
Medication Safety Database
37. Not checking Administration History
Action
Enhancement
Last dose administered viewable in Administration screens
Delivered v8.1.1
Medication Safety Database
38. Lessons learned
Compliance poor
with workarounds when > 1 step
when > 1 extra mouse click
Professions need to understand each others workflow
Users need to be familiar with new types of errors
There is always another way … you just need to find it
Medication Safety Database
39. Pharmacist Interventions (Epiphany) Grade 1-3
Pre 2 years vs Post 1 year
All n = 14959
Pilot Ward n = 941 (6.3%)
MedChart Involved n = 81 (21.5%)
Sub-analysis
Place in Medication Use process
Phase in Patients Admission
Event Severity
Type of Event
Medicines involved
Pharmacist ‘Error’ Interventions
40. Event Severity
Place in the Medication Use Process
Transcribing
Type
Illegal/Illegible/Incomplete
Wrong Drug Regimen
Wrong Dose Regimen
Duplicate Therapy
Pharmacist ‘Error’ Interventions
41. Wrong Drug
New workflow = Selection of medicines from list of
forms & strengths
Pharmacist ‘Error’ Interventions
42. Wrong Drug
Action
Training
Screen shots of common mistakes
Importance of checking full screen
Pharmacist ‘Error’ Interventions
43. Duplicate therapy despite DUPLICATION decision support
Alert Fatigue
Due to current medicine definition “within past 24hrs”
ie any Edit to a medicine resulted in an Alert
Action
Change definition of current medicine to “0 hours”
Manage risk of “stats” duplication Given = Ceased = No warning
Change Patient Summary screen to default to past week
Train Drs to check Patient Summary screen for recently ceased “Stats”
Pharmacist ‘Error’ Interventions
44. Medicine
Events for high risk or error prone drugs
warfarin
morphine
oxycodone
diltiazem
insulins
metoprolol
Pharmacist ‘Error’ Interventions
45. Lessons learned
Prescribers need support in new prescribing requirements
Infrequent users forget workarounds
High risk drugs are complicated to prescribe
Need to audit & develop new strategies / workflows
Alert fatigue
Minimise Alerts where ever possible
Need new categorisation of errors for ePrescribing
More efficient recording & data analysis
Pharmacist ‘Error’ Interventions
46. Process issues
Transfer
Paper and electronic chart used concurrently in error
Integration +++
WebPAS
Non-MedChart wards - “Meds Current at Transfer” not easily identified
Appointments - Pharmacist annotations fall off
Pharmacist Prescriber Advice
Post Go-Live only
47. Transfer
Actions
Training
“Spot the 7 errors”
Pharmacist Prescriber Advice
Post Go-Live only
49. Actions
Training
Pharmacists trained in areas problematic for Doctors/Nurses
Enhancements +++
Ability to print chart as at transfer
Ability to electronically re-chart once transferred back
Pharmacist annotations at transfer
ADT messages not recognised by MedChart
Pharmacist Prescriber Advice
Post Go-Live only
50. Lessons learned
Easier to train small, stable group in workarounds
Pharmacists backstop for Multi-step processes
Withholding,
Alerts,
Qualifiers,
Duration
Integration a work in progress
Multiple issues at transfer
Dual systems increase risk of errors
Pharmacist Prescriber Advice
Post Go-Live only
51. Complex
CONTEXT is everything
HOW is as important as WHAT
What we found out…
52. What we found out…
…the VALUE PROPOSITION…
...Will need to learn to do things differently,
but there will be benefit in return…
53. ….You don’t know what you don’t know…
Environment & product continually changes
Key Lessons
54. needs to be ongoing & intensive
Engagement wanes
High user turnover
Infrequent users struggle with workarounds
Regular users don’t see the need for training updates
Key Lessons
55. Constantly review
Educate professions about each others workflows
Educate about new types of errors
HOW IS MORE IMPORTANT than what
Key Lessons
56. To be expected, but..
Will be modified by staff & lead to unintended consequences
Some workarounds are safer than others
Need to be identified
Constant challenge
…..
Key Lessons
57. Maintaining End User Engagement
Withholding
Dual systems / Transfer
to understand context-related unintended consequences but then…
Key Lessons
58. Vendor
Talk different language so define problems / solutions clearly
Clarify, re-clarify & re-visit
Other DHBs valuable resource
Liase regularly & re-visit
Site visits invaluable
Key Lessons
59. Sites / Wards have different needs
Flexible
Configurable options
Site collaboration
Process needs to be supported Nationally
Key Lessons
62. Table 1 MedChart Associated Events & Issues Identified at TDHB
Type Description Medication
Incorrect
Start Date/Time
Regularly” scripts default to todays date, but not due till later in the month
Start time defaults to next available due dose & was not edited
Incorrect Timing
Medicines (such as Madopar) prescribed twice daily at 8am/8pm when
should be tailored
Frequencies have pre-specified default times which may not be appropriate
for certain medicines, however a Dr would not previously had to specify
exact time . eg three times daily (= 8am, Noon, 1800) for medicines that
need to be taken on an empty stomach
Medicines prescribed at mealtimes that should be on an empty stomach
Medicines prescribed (via protocols) apart from meals that should be with
meals
Eye drops charted hourly and need qualifier to say “during waking hours”
Incorrect Frequency Frequency defaults to ‘once daily’ and was not edited
Frequency &
Administration times
out of sync
Admin times can be edited by nursing /pharmacy staff, but this may not
match the prescribed frequency (which can only be changed by prescriber)
eg “in the morning at 1800”
Duration issues
Once duration complete, script ceases and in error may not be continued (or
have dose review) when should be
Prescribers do not want script to “fall off” so put no duration = overtreatment
and potential resistance
Editing script, duration defaults to original duration and get overtreatment
and potential resistance
Prednisone
63. Table 1 MedChart Associated Events & Issues Identified at TDHB
Type Description Medication
Incorrect Medicine drug database categorisation of medicine contributed to confusion Hep saline
Incorrect
Strength of medicine
Dr would previously have had to chart dose only (not strength), but now
has to chose down to strength, and when editing dose downwards, the
strength should have been changed also
incorrect medicine strength & for what on stock (dose charted in mL)
Enoxaparin
Methotrexate
Morphine
Incorrect
Form or Formulation
Dr would not have had the choice between the 2 different preparations and
choose the wrong one
eg MDI vs DPI,
Capsules vs Dispersible Tablets,
Immediate Release vs Slow Release,
Otrivine Menthol Nasal Spray vs Otrivine Nasal Spray
Brand issues
Cannot chart by brand unless you know the brand name
eg insulin should be charted by brand, but if search by insulin, you do not get the
Penmix brand option (as it does not contain insulin in its description)
Pharmacist annotations (eg for brand) drop off when patient goes for a clinic
appointment
Route issues Change to a PEG tube requires re-charting of all medicines
Vancomycin infusion given orally for C. Diff
Duration issues
Once duration complete, script ceases and in error may not be continued (or have
dose review) when should be
Prescribers do not want script to “fall off” so put no duration = overtreatment and
potential resistance
Editing script, duration defaults to original duration and get overtreatment
Prednisone
64. Table 1 MedChart Associated Events & Issues Identified at TDHB
Type Description Medication
Duplication of Medicines
Due to alert fatigue
Due to duplicate warnings not firing for locally added pack
Due to different script types for the same medicine displaying on different
tabs (regular vs prn vs stat vs variable dose)
Due to lack of familiarity with how to use variable dose functionality to edit a
dose
Withheld medicines
Withheld medicine given when no place in the process was set for alert to fire
(ie passive alert only)
Withheld medicine was given when “at administration” alert was overridden
Withheld medicine given when “at administration” alert date was set
incorrectly (ie had expired the previous evening)
Minimum Dose Interval
with PRN medicines
If a dose is given late on the first day (where minimum dose interval is set to 1 day),
the subsequent doses must be given late every day as not available until late
Issues with the process
of using the electronic
chart
Medicines omitted on transfer from paper chart to MedChart
Paper chart & electronic chart being used concurrently
Resupply, Source information and Administration comments fall off the electronic
chart when a patient goes for an appointment
65. ADMISSION TO HOSPITAL DISCHARGE FROM HOSPITAL
Key Messages Key Messages
Medicine and allergy
information from:
• Patient (+ family,
caregivers)
• GP/specialist
• Community
pharmacy
• Rest homes
• Other hospitals
• Ambulance
Allergy Warning + ADR
▪ Input by
pharmacists
▪ 3+ sources used
▪ Discrepancies
listed as
unintentional /
intentional
Medicine and allergy
information to:
Dx summary
(inc DMCS)
Dx scripts
DMCS
Yellow
cards
Patient info leaflets
Patient
Community
pharmacy
Rest homes
Other
hospitals
Discrepancies must be resolved by a doctor within 24 hours of arriving in ED
Patients own medicines into “green bag”
DMCS = discharge medicines changes summary
(Automated Drug Distribution
System)
66. Pyxis “batching”
Retrieve ≥ 1 patient at a timeDRUG ROOM
Administer 1 patient at a time BEDSIDE
…but only 1 Administration step in MedChart
How did other sites manage time delay between Retrieval &
Administration?
National workshop
Process mapping
Retrieval annotated on paper chart in drug room as a separate ste
TDHB
67. Regular scripts defaulting to todays date
New workflow = Dr to specify start date/time rather than just frequency
Actions
Education of Nurse in Doctor workflow & new types of errors
Training scenarios
Enhancement (blank default)
Delivered 8.1.1
Pharmacist ‘Contribution’ Interventions
68. Medication Safety Database (Grade 1-5)
Place in Process sub-analysis by Type
Prescribing
Extra dose (withholding) 25%
Duplication 25%
Wrong Drug (strength /dose mismatch) 25%
Omission 25%
Transcribing
Extra dose (wrong start date) 75%
Omission 25%
Medication Safety Database
69. Medication Safety Database (Grade 1-5)
Place in Process sub-analysis by Type
Administration
Extra dose
withholding 44%
wrong start date 22%
other 6%
Wrong dose (strength) 11%
Wrong time 11%
Missed dose 6%
Medication Safety Database
70. Warfarin new workflow
Medicines arranged in “tabs” by script type
Editing dose workflow different from other medicines
Had to select brand (incorrect default)
Pharmacist ‘Error’ Interventions
71. Action
Warfarin
Rules to alert infrequent prescribers to unusual workflow
Removal of “ALL” tab
Enhancement
Change default configuration to brand “unspecified”
Pharmacist ‘Error’ Interventions
72. Pharmacist Contributions (Epiphany) Grade 1-3
Pre 2 years vs Post 1 year
All n = 6061
Pilot Ward n = 919 (15.2%)
MedChart Involved n = 26 (9.8%)
Pharmacist ‘Contribution’ Interventions
73. Administration & Formulation Advice
Frequency & Administration times out of sync
Default frequency morning = 8am
Frequencies have pre-specified default times
Editing of Administration times by nursing staff
Regularly scripts
default to todays date
Formulations
Dispersible vs normal, DPI vs MDI
Pharmacist ‘Contribution’ Interventions
74. Administration & Formulation Advice
Frequency & Administration times out of sync
New workflow = Dr to specify administration times ; frequency defaults
Actions
Rules to warn when Administration times need to differ from defaults
Change configuration “mane 08:00” to “od 08:00”
Training scenarios
Education re: limitations for Nurse being able to “edit administration
times”
Pharmacist ‘Contribution’ Interventions
75. Lessons learned
Nurses need to understand Drs new workflow (eg defaults) &
potential for new types of errors
Change in work responsibilities created tensions
Dr now needs to think about nursing workflow (Admin times)
Education of Drs about nursing workflow
Pharmacist ‘Contribution’ Interventions
76. Incorrect strength for ward stock
Morphine oral 2mg/ml prescribed as first choice on list
Dose displays as mL on Administration screens
BUT only 10mg/mL held on ward stock (2mg/mL Paeds only) & on Quicklist
Action
Change 2mg/mL to NON-FORMULARY
to guide prescriber to select 10mg/mL
Pharmacist Prescriber Advice
Post Go-Live only
77. Medication Issues
Incorrect strength for edited dose
Incorrect strength for ward stock
Dose edited but not qualifier
Route issues
High frequency medicines
Minimum dose interval for PRN medicines
If dose given late on first day, subsequent days doses can’t be
started till late
Pharmacist Prescriber AdvicePost Go-Live only