The Role of Technology in the Medication Use Process

Technology and Health Care

U
ntil recently, the majority of technology acquisitions have consisted of basic stand alone
computer systems, which were primarily used for data input to increase each
departments efficiency with financial accountability measures. These computers were
generally installed in the pharmacy, radiology, and laboratory departments, and could also be
found in the administration and business offices. Each department was allowed to evaluate and
purchase their own unique computer system preventing any integration of data or dissemination
of critical patient information, which is indispensable in providing safe care. But even as
improving technologies have emerged allowing for seamless integration of information to occur,
most organizations have shown little interest or incentive to incur the huge costs associated with
replacing their present nonintegrated computer systems.

Influences of 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 television and newspaper accounts that reported the tragic death of a
patient from a preventable adverse drug event (ADE) due to an inadvertent administration of a
massive overdose of a chemotherapy agent over four days. This particular error became a
watershed even for patients, practitioners and healthcare organizations alike.

A root cause analysis of the error revealed that there was no malpractice of the error revealed
that there was no malpractice or egregious behavior, but that excellent, conscientious, and caring
pharmacists and nurses simply interpreted an ambiguous handwritten chemotherapy order
incorrectly. In restrospect, had technology been available, the physician would have entered the
medication order into a Computerized Prescriber Order Entry (CPOE) system and this
heartbreaking error would not have happened.

It has been estimated in the outpatient setting that indecipherable or unclear orders resulted in
more than 150 million telephone calls from pharmacists and nurses to prescribers requiring
clarification, which not only is time-consuming for practitioners, buts estimated to cost health
care systems billions of dollars each year. Thus, the availability of critical clinical information
needed at the point-of-care during prescribing, dispensing, and administering cannot only
improve time management and contribute to cost savings though improved utilization of
medications, staff and patient satisfaction, but most importantly reduce the incidence of error.

In Febraury 2004, the Federal Drug Agency required medications to have machine readable bar
coding. IN an optimally acute-care bar coded environment, a nurse would scan his/her bar coded
identification badge at the beginning of each medication administration time, the patients bar
code identification band, and the intended drugs bar coded label with a bar code scanner. A
mismatch between the patient, the drug packaging applied during manufacturing or repackaging,
an incorrect time, dose, route, and the patients medication record would trigger a warning,
prompting the nurse to investigate the discrepancy before administering the medication.
Computerized Prescriber Order Entry (CPOE)

Health care 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 from a traditional paper-based system that
relies on the unaided mind to automated order entry, record keeping, and clinical care. These
factors, including accessing patient information spread across multiple organizations that may be
unavailable, especially in large organizations and therefore, medical care would be provided
without pertinent information. The structure of the patients record often makes it difficult to
locate valuable information, illegible handwritten entries by health care practitioners, and for
those patients with chronic or complex conditions, the records can increase to multiple volumes
over many years. These problems result in a variety of communication breakdowns when
providing health care to patients from the duplication of services, delays ion treatment, increased
length of stay and increased risk of medical errors. Additionally, human memory-based
medicine can be inaccurate or not recalled.

Currently, practitioners rely heavily on the unaided mind, which has been proven to be
unreliable, to recall a great amount of detailed information. Actually, only a portion of medical
knowledge is ever loaded into the prescribers minds and not all of this knowledge is retained.
Also, much of the retained learned knowledge is health care quickly becomes obsolete with no
assurance that they will acquire any new knowledge. Even if new knowledge is learned and
retained, it is impossible for practitioners to integrate all knowledge with an infinite amount of
patient data in a shirt period of time. Faced with knowledge overload, prescribers and other
practitioners tend to fall back on clinical judgment rather than organized knowledge.

There are also many barriers that lead to ineffective communication of medication orders that
include issues of medication orders that include issues with illegible handwriting, use of
dangerous abbreviations and dose designations, and verbal and faxed orders. Studies have
shown that as a result of poor handwriting, 50% of all written physician orders required extra
time to interpret. Illegible handwriting on medication orders has been shown to be a common
cause of prescribing errors, patient injury and death have actually resulted from such errors.
Illegible ores may also lead to delays in the administration of medications. In order to clarify
these illegible orders, the health care practitioners workflow is typically interrupted.

The use of a CPOE system has the potential to alleviate many of these problems. CPOE can 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. But there
are many other potential enhancements that even a basic CPOE system could offer to further
enhance safe medication ordering practices including
1. features unique to the acute-care setting, ambulatory care setting or both;
2. allow prescribers to access records and enter orders from their office or home;
3. prescriber selectable standardized single orders or order sets;
4. implementation of organization-specific standing orders based on specific situations such
as before or after procedures;
 5. 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 and progress notes or active feedback systems to
provide clinical decision-making tools by providing specific assessments or
recommendations through alerts and reminders or even therapeutic suggestions at the
time the order is given.

The use of an online electronic medication administration record (MAR) is likely to be more
accurate than the 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 log of the medication administration. Additional levels of
functionality can include some of the following features:
Increased accountability and capture of charges for items such as unit-stock medications;
Up-to-date drug reference information from online medication reference libraries. This
could include pictures of tablets or capsules, usual dosages, contraindications, adverse
reactions, and other safety warnings, pregnancy risks factors and administrative details;
Customizable comments or alerts (e.g. look alike/sound alike drug names) and reminders
of important clinical actions that need to be taken when administering certain medications
(e.g. respiratory intubation is required for neuromuscular agents);
Monitoring the pharmacy and the nurses response to predetermined rules or standards in
the rules engine such as alerts or reminders for the pharmacists or nurse. This includes
allergies, duplicate dosing, over or under dosing, checking for cumulative dosing for
medications with established maximum doses such as colchicines;
Reconciliation for pending or STAT orders (i.e. a prescriber order not yet verified by a
pharmacist). The ability of the nurse to enter a STAT order into the system on
administration that is linked directly to the pharmacy profile and prevents the duplicate
administration of the same medication;
Capturing data for the purpose of retrospective analysis of aggregate data to monitor the
trends (e.g. percent of doses administered late and errors of omission). However, this
analysis should not be used to assess employee performance, especially if it could lead to
punitive action.
Verifying blood transfusion and laboratory specimen collection identification.

It is vitally important to its success that affected staff members and specifically front line nurses
are involved in all decisions related to the purchase, education and implementation of bar code
technology. Before embarking on a BPOC implementation, it is critical to anticipate potential
failures and develop contingency plans for unexpected results. Of course, a stringent testing
phase should also be built into the system rollout phase suing a technique such as failure mode
and effects analysis (FMEA) to provocatively address potential sources of breakdowns,
workarounds or new sources of medication errors.

The interaction between nurses and technology at the bedside is important and must be
continually evaluated for safety. Nurses tend to develop workarounds for ineffective or
inefficiently designed systems. One example includes nurses circumventing the normal
procedures by removing or duplicating the patients bar code wristbands and then scanning the
corresponding medications for each patient while in the medication room prior to or after
medication administration. Another workaround method includes the scanning of a surrogate bar
code by having a sheet of paper with multiple bar codes of commonly used medications rather
than the one unique medication package for each patient.

It is important to understand that the successful implementation of an effective BPOC system

forces nurses to accept and change some of their long-held practices when administering
medications to achieve higher level of medication safety. When BPOC technology is used
correctly,
it forces the nurses to always be compliant with the proper identification of patients,
it documents real time administration
it acts as a double check and
it does not allow the nurse to prepare medications for multiple patients at tome time or
prepour medications prior to the appropriate administration time.

One major issue initially hindering the widespread implementation of the BPOC systems lies
largely with the pharmaceutical industrys apparent unwillingness to adopt a universal code
standard and apply a bar code consistently to the container of all medications, including unit-
dose packages.

Further complicating the issue is the extended lag time between the launch of new medications
and their availability in unit-dose packaging. Additionally, unit-dose packaging for some
established products have been discontinued. At this point, hospital pharmacists that employ bar
code technology must repackage many medications and relabel each with a bar code. This can
only be done at considerable cost in manpower and/or automated repackaging equipment. In
addition, the chance of a medication error occurring is increased because doses must be taken
from their original container and then repackaged or relabeled and there could be an error in the
application of the correct bar code label or in choosing the wrong medication. One medication
error report includes a scenario where a facility that utilized a bard code medication
administration system for their patients where not all injectibles used at the organization had
manufacturers bar codes on the vials or ampules, pharmacy technicians had to generate
computer printed bar codes for those products.

The use of BPOC systems can possibly introduce new types of medication errors. Although, due
to the low incidence of organizations using BPOC and few medication errors reported, it can
only be hypothesized that some of the following types of errors could occur, especially if the
system includes only the most basic functionality:
Omissions: After the patients bar code armband and medication have been scanned, the
dose is inadvertently dropped onto the floor. This results in a time lapse between the
documentation that the medication was supposedly administered and the actual
administration after obtaining of a new dose.
Extra dose: An extra dose may be given when there are orders for the same drug to be
administered by a different route. For example, if one nurse gives an oral dose and is
called away, the covering nurse administers the dose intravenous (IV). The problem
arises when there is no alert between profiled routes of administration indicating that the
medication was previously administered by one route that is different than the second
route.
 Wrong drug: In situations when the nurse administers a medication, which has not been
labeled with a bar code.
Wrong dose: In situations when the nurse has difficulty scanning medication and
proceeds to scan the medication twice. This results in a double dose when only one
table is to be administered.
Unauthorized drug: An order to hold a medication unless a lab value is at a certain level
such as aminoglycoside.
Charting errors: Distinguishing the indication for the administration of the medication.
Wrong dosage form: Certain drug shortages may force a pharmacy to dispense a different
strength or concentration (mg/mL) other than what is entered in the BPOC software.

Automated Dispensing Cabinets

Traditionally, hospital pharmacists provided medication for patients by filling patient-specific

bins of unit-dose medications, which were then delivered to the nursing unit and stored in
medication carts. The ADC is a computerized point-of-use medication management system that
is designed to replace or support the traditional unit-dose drug delivery system. The devices
required staff to enter a unique logon and password to access the system using a touch screen
monitor or by biometric identification. Various levels of system level access can be assigned to
staff members, depending on their roles in the medication-use process. Once logged into the
system, the nurse can obtain patient-specific medications from drawers or bins that open after a
drug is chose from a pick list.

The rationales behind the widespread acceptance of this technology are the following:
Improving pharmacy productivity: The streamlining of the dispensing process due to the
reduced number of steps from filling each patients individual medication bins to filling a
centralized station. It also has the potential to reduce time needed to obtain missing
medications.
Improving nursing productivity: The time spent gathering or obtaining missing
medications can be reduced. Also, the turnaround time in obtaining newly ordered
medication is decreased.
Reducing costs: Increased pharmacist and nursing productivity, which frees them from
time-consuming processes and allowing more time for patient and clinical interactions.
There is also a reduction in inventory and containment costs associated with expired
medications.
Enhancing patient quality and safety: ADC that have built-in decision support systems
that warn users of drug-drug interactions, drug allergy interactions, drug-lab interactions,
drug-drug duplications, and so forth.

Implementation of Technology

Implementing any form of technology into a healthcare organization can be an imposing task.
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. Therefore, it is vitally important to thoroughly plan for this process and to remember
your goal is to improved clinical processes, which can be facilitated by technology.

Foremost, the process will require total commitment from the organizations executive and
medical leadership as well as all staff members who will be affected by the implementation. It is
of utmost importance that the leadership sends a clear message that this is important to patient
safety and that they provide their unwavering support and financial backing as the project
evolves. Lacking this level of commitment will greatly increase the chance of failure.

Identifying physician champions at a very high level in the organization is crucial and involving
them in the decision-making and planning process will help to persuade practitioners to buy
into technology. In addition, identify an interdisciplinary team of key individuals who can
collaborate on an effective and realistic plan for the implementation, including the front line
clinical staff. The implementation team will have to address the following:
Outlining the goals for the type of automation to be implemented to improve safety,
decrease costs and eliminate handwritten orders.
Developing a wish list of desired features and determining which one, given budgetary
constraints, are practical.
Investigating systems that are presently available
Analyzing current workflow and determining what changes are needed.
Identify the required capabilities and configurations of the new system (development of
rules, protocols, guidelines, drug dictionaries, etc.)
Sell the benefits and objectives of automation to the staff
Development of the implementation plan by setting realistic time frame expectations.

As soon as the new system is installed, it is important to commit in a meaningful way to its
continual monitoring and improvement. The health care environment is a dynamic one in which
opportunities for new errors will likely arise. Identify key measures that will help you determine
whether your systems are really improving safety and quality and reducing costs.