1

Medication Safety in Informatics

Week 2
 2
The Role of Technology in Medication Use,
Process and Safety:
✓Bar-coding and RFID(Radio Frequency ID)
✓Smart Pumps
✓ADC (Automated dispensing cabinet)
✓CPOE
✓Medication Reconciliation
✓Workarounds and the impact on patient safety
 3
At the end of the class students will be able to:

Explain Bar-coding and RFID

Discuss Smart Pumps
Describe ADC
Explain CPOE
Discuss Medication Reconciliation
Explain Workarounds and the impact
on patient safety
 Introduction: 4

 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 5
 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.
 Influences on the Adoption of Technology
6
 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.
 Influences on the Adoption of Technology
7
 Inoutpatient setting, 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.
 Bar Code Technology 8
 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

Medication safety 9
 Examples of technologic tools 10

 commonly seen in many hospitals

today include Computerized

Provider Order Entry (CPOE)

with decision support and automatic

dispensing carts, also known as

medication dispensing robots.

11
Computerized Provider Order Entry (CPOE)
12
 Computerized Prescriber Order Entry
13
 Computerized physician order entry (CPOE) - Electronic
entry of medical practitioner instructions for the
treatment of patients (particularly hospitalized patients)
under his or her care.
 These orders are communicated over a computer
network to the medical staff or to the departments
(pharmacy, laboratory, or radiology) responsible for
fulfilling the
order.
 Computerized Prescriber Order Entry
14
 CPOE decreases delay
✓ Order completion
✓ Reduces errors related to
handwriting.
✓ Allows order entry at the
point of care or off-site.
✓ Provides error-checking for
duplicate or incorrect doses
or tests.
✓ Simplifies inventory and
posting of charges.
CPOE is a form of patient
management software.
CPOE
15
16
 Advantages of CPOE:
17
✓ 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 improved

✓ CPOE would not only improve patient safety but also

increase efficiency, productivity, and cost effectiveness.
 Disadvantages of CPOE:
18
 Errors still possible : - Direct order entry eliminates some error
checking that may occur when several individuals are involved
in the process.
 Alerts - - alerts can become annoying if they are set at a too-
sensitive level. Many times the alerts system is then
suppressed or ignored, which can result in an increase in
errors.
 Multiple steps: - Often software design results in multiple
screens and clicks in order to complete and sign an order. This
can be time consuming, especially in systems that are slowed
by multiple users during peak usage times, etc.
 Access : - Computer access is required and may not be easily
available when the physician is off site or when there are too
few computer stations available during peak usage times.
19
 BAR CODE 20

 A bar code is a graphic representation of data (alpha,

numeric, or both) machine-readable.
 It contains a 12-digit product number. Bar codes are a
way of encoding numbers and letters by using a
combination of bars and spaces of varying widths. Both
the lines and spaces are read. Bar codes are a fast,
easy, and accurate way of entering data
Bar Code-Enabled Point-of-Care
Technology 21
 Bar code
22
https://www.youtube.com/watch?v=eig09mK3voQ
23
 24

 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
25
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
Additional levels of functionality can
26
Include some of the following features:
❑ 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.
Bar Code-Enabled Point-of-Care Technology
27
 Negative effects include:
1. Nurses were sometimes caught “off guard” by the
actions taken by the BPOC software.
2. Nurses found it more difficult to deviate from the
routine medication administration sequence with the
BPOC system.
3. Nurses felt that their main priority was the timeliness
of medication administration
4. Nurses are ‘controlled’ by technology, Interfered with
other responsibilities, judgment, flexibility.
 Radio Frequency IDentification 28
(RFID)
RFID tagging is an ID system that uses
small Radio Frequency Identification
Devices for identification
and tracking purposes. An RFID tagging
system includes the tag itself, a read/write
device, and a host system application for data
collection, processing, and transmission.
 RFID
29

 RFID tags are in wide use within hospitals to enable rapid,

highly accurate asset management. They are applied to or
embedded in hospital assets to allow staff to rapidly locate
and accurately inventory high cost assets.
 Additionally, RFID tagged assets are more difficult to steal
or relocate. However, healthcare assets require very specific
and challenging requirements in an RFID tag - the tag may
have to survive multiple autoclave cycles or exposure to
gamma sterilization, or they may need to be of a form factor
and of a rugged design suitable for embedding in a medical
device.
 RFID
30

Interpreting a barcode requires a direct

line of sight to the printed barcode, so it
is printed on the outer side of the
product and is thus, subjected to greater
wear and tear. It also limits the re-
utilization of barcodes.
 Embedded RFID tags provide multiple
benefits for medical devices 31

 Rapid and easy asset inventory tracking

 Configuration and maintenance history tracking -

origin, revision level and manufacturing date

 Characterization data for interchangeable parts -

probes, scopes and robotic end effectors can
communicate wirelessly with their host device to
provide identity and characterization information

 Use cycle counting for devices with limited lives

 Sterilization history validation and storage .

Automation 32

 Automation : any technology , machine or

device linked to or controlled by a
computer and used to do work

 Automation is designed to streamline and

improve the accuracy and efficiency of
the medication use process
Goals for the use of automation 33

 Reducing costs
 Improving operating efficiencies
 Growing revenues
 Enhancing safety and quality
 Integrating and managing data
 Providing outstanding customer service
Factors that led to Automation 34

 Shortages of qualified pharmacists

and technicians.

 Shrinking of operating budgets

 Automation.. 35

Advantages:
 Improve efficiency(Reduce pharmacy staff and
work load)
 Improve accuracy, reduce errors
 Improve documentation
 Authorized access only, enhance security
 Reduce job stress and staff turnover
 Shorten med pass time for nurses/ caregivers
Automation.. 36

Disadvantages:

 Additional training and technical help

 Downtime, system failure and inflexibility

 Cost and space issues

Automated dispensing Cabinets
37
(ADC)
 Is a computerized point-of-use medication-
management system that is designed to
replace or support the traditional unit-dose
drug delivery system.
Advantages of ADC: 38

Improving pharmacy productivity

Improving nursing productivity

Reducing costs

Improving charge capture

Enhancing patient quality and safety

Drawbacks/ disadvantages of ADC:
39

1. Lack of pharmacy screening of medication order prior to

administration

2. Choosing of the wrong medication from an alphabetic

pick list

3. High-alert medications placed, stored, and returned to

ADC’s are problematic.

4. Storage of medications with look-alike names and/or

packaging

5. The development of “workarounds”

“Smart” Infusion Pump Delivery Systems
40

 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.
41
“Smart” Infusion Pump Delivery Systems..
42

 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.
Medication Reconciliation 43

 Process of identifying the most accurate list of all

medications a patient is taking

- Name, dosage, frequency and route

 Use this list to provide correct medications for patients

anywhere within the health care system

 Compare the patient’s current list against the

admission, transfer or discharge orders.
 Three Steps 44

 Verification—collection of medication history

 Clarification—ensuring medications and the dosages are
appropriate
 Reconciliation-Documenting the changes in the orders.
➢ Drug is started
➢ Drug is discontinued
➢ Dose of drug changed
➢ Frequency of administration is changed
Workarounds and the impact on patient safety
45

 Work procedures that are undertaken in order to address

a block in work flow.
---------Ash, berg

 “one lesson that all nurses learn as soon as they start to

practice in that part of job is to constantly find ways to “
just get things done’ despite of the obstacles of the work
place”.
----- Vestal (2008)in nursing and the Art of the
workaround.
Conditions leading to workarounds:
46
blocks in workflow

 Policies/ laws/regulations
 Protocols/guidelines
 Poorly designed process
 Technology
 People
Intentionality of blocks 47

 Intentional Blocks: typically involve

forcing functions or safety procedures ex.:
medication double check
 Unintended Block : Printer not working
 The Impact On Patients 48

✓ Workarounds are frequently cited as a patient safety

problem.
✓ Only recently has research started to explore this
suggestion directly.
✓ Koppel et al(2008): 15 different types of BCMA
workarounds, 31 types of causes of workarounds.
✓ Strongest link to errors to data.

http://videos.med.wisc.edu/videos/3530
 Reference 49

 LaDuke, S (2009) Playing it safe with bar code

medication administration. Nursing 2009 39(5)
32-34

 Stachowicak, ME. (2013)

 Nelson and Staggers, Chapter 1 and 2

 NLN Position Statement 2008 on Informatics

50