Improving Drug Safety with the use of Information Technology

Dr. Pauline Lai Siew Mei Department of Primary Care Medicine Faculty of Medicine, University of Malaya

Introduction

Medication errors, adverse drug events, or injuries due to drugs, occur more often than necessary
Lazarou J, et al. JAMA. 1998;279:12001205

Incidence

Medication errors receive less public attention compared to aeroplane and automobile crashes.
Leape LL, et al. N Engl J Med. 1991;324:377384.

Overall incidence for serious adverse drug reactions in hospitals is 6.7% Lazarou J, et al. JAMA. 1998;279:12001205
Between 28% and 56% of adverse drug events are preventable Bates DW, et al. JAMA. 1995;274:2934.

Role of automation in the medication process

Transcription Electronic prescribing Dispensing Robots, bar coding, Automated dispensing devices Medication administration Bar coding, automated dispensing devices Electronic medicine administration Monitoring ADR
Source: BMJ. 2000 March 18; 320(7237): 788791.

Transcription
Electronic prescriptions

Prescribing medications
Most

common form of therapeutic intervention by Drs to influence patients health

Maxwell & Walley, 2003

Inappropriate

prescribing: Most common cause of iatrogenic disease Frequent source of negligence claims against Drs & healthcare providers

Forcing functions of I.T.

Prescriptions prescribed electronically can be forced to be legible and complete

Access the electronic PMR to obtain a complete medication history

Decision support
Performs checks in real time

Checks drug interactions & duplications

Drug templates
Provides a guide to the clinician on the appropriate drug dosage and route of administration

Drug doses can only be prescribed w/in the min or max dose range, with an appropriate route of administration & duration A dose that is 10x as large will be ordered less frequently if it is not one of the options on the menu

Record allergies

Additional notes

Chemotherapy protocols
Each regime can be preset within the system Ensures that the correct drug(s), dose and route of administration is prescribed for that particular regime

Assist with calculations

Calculates the body surface area

Displays calculation
Asks if it is correct. The dose is then checked against a table of doses, with daily and weekly limits. If a dose limit is exceeded the order can be rounded down / suspended until it can be reviewed and approved

Make knowledge more readily accessible

Providing access to drug information

Use of hand-held devices for rapid and instant access will improve safety
http://www.epocrates.com http://www.unboundmedicine.com http://www.micromedex.com

Drug information sources

Within a clinical application

Impact of the use of electronic prescribing in an outpatient setting in the UMMC

P.S.M. Lai1, S.S. Chua2, C.P.L. Tan3
1Pharmacy

Unit, UMMC 2Dept of Pharmacy, University of Malaya 3Dept of Primary Care Medicine, University of Malaya

Objectives

To investigate any difference in

Doctors consultation time Time taken for outpatient pharmacy to dispense medications

before and after the implementation of e prescribing

Methodology
Period of study: Phase 1: 8 April 6 May 2002 Implementation of e prescribing May 2002 Phase 2: 2 Sept 28 Sept 2002

Study site: Primary Care Clinic, University Malaya Medical Centre

Sampling frame

Included

All patients attending the Primary Care Clinic between 0800-1500 hours during the study period

Excluded

Patients prescribed non-formulary items Patients admitted to the ward

Data collected

Time taken by the doctor to see each patient

Time taken by the outpatient pharmacy to dispense medications

Demographic data
Phase 1 No. of patients Mean age (years) 2663 43.50 22.00 Phase 2 1485 49.25 19.40

Fewer patients were included in Phase 2 as not all patients were prescribed electronically

No. of diagnoses per patient

No. of diagnoses One Two Phase 1 1792 (67.5%) 817 (30.8%) Phase 2 1124 (77.7%) 304 (21.0%)

Three
Four

42 (1.6%)
2 (0.1%)

17 (1.2%)
1 (0.1%)

Waiting times

Waiting times
Phase 1 Duration in Drs room (mins) Min 2.00 Phase 2 1.00

Max p=0.669
Pharmacy waiting time* (mins) *p<0.001 Min Max

415.00
1.00 222.00

216.00
1.00 128.00

Mean 22.2 32.4 22.7 31.0

Mean 27.6 18.7 7.2 11.2

No. of items dispensed & not dispensed

Phase 1 No. of items received No. of items not dispensed % of items not dispensed* (*p<0.001) Mean no. of items per prescription (p=0.617) 5093 179 3.51 2.63 1.33 Phase 2 4020 3 0.07 2.71 1.53

No. of prospective pharmacy interventions

Phase 1 Sample size 1926 Phase 2 1485

No. of prescriptions intervened* (p<0.001) No. of prospective problems detected Total no. of drugs prescribed Drugs not available

263 (13.6%)
402 5093

3 (0.2%)
3 4020

179

Electronic prescribing

Reduced patient frustration

Caused by delays Not being told in advance to pay the full cost of the drug

Medication is ready before the patient arrives in pharmacy

Prescribing electronically

A prescription for a single item took slightly more time to enter electronically than to write by hand
Prescriptions for multiple medications took less time Doctors became more proficient in using the system as time went on

Bates DW et al, 1994:996 Abstract from 18th Annual Symposium on Computer Applications in Medical Care

Conclusion
Electronic prescribing

Simplified the dispensing process & reduced pharmacy waiting time by about 4x Did not increase doctors consultation time Improved the efficiency of the prescribing process through online drug availability & formulary benefits at the optimal point between the doctor & patient

Dispensing
Robots Bar-coding Automated dispensing devices

Robots for filling prescriptions

May reduce error rates

Used in some large hospitals especially in the outpatient setting One unpublished study: robot decreased the dispensing error rate from 2.9% to 0.6% Pharmacy Robot in Scotland saved their Trust 700,000 http://www.bbc.co.uk/news/health11562928

PE Weaver and VJ Perini, American Society of Health System Pharmacists, 1998

Bar-coding of medications

Ensures that drug at hand is the intended one Used to record who is giving and receiving it Can record various time intervals May reduce error rates to about 1/6 to keyboard entry Less stressful to workers Major barrier to implementation: drug manufacturers not able to agree on a common approach (to be legislated?) Concord Hospital, New Hampshire, USA 80% fall in medication administration errors
D DePiero, personal communication

Baxa compounder
Interfaced with a Pharmacy Information System Automated Total Parenteral Nutrition Compounder

CytoCare

Automates the compounding of hazardous IVs, used for chemotherapy, monoclonal antibody therapy, and genetic therapy
Improves accuracy, efficiency and pharmacist safety

http://www.devonrobotics.com/cytocare/tv/

Administration
Bar-coded patient identification Automated dispensing devices Automated medication administration record

Bar coded patient identification

Designed to prevent accidents, such as the performance in one patient of a procedure intended for another patient
Verification of the correct drug for the correct patient

Automated dispensing devices

Can be used to hold drugs at a location & dispense only to a specific patient
If linked with bar coding & interfaced with hospital information systems and electronic prescribing can decrease medication error rates substantially Without these links, effect is unclear: one study showed an increase in medication errors

Barker KN et al. Am J Hosp Pharm. 1984;41:13521358

Electronic medication administration

Touch-screen administration application. List of doses due for administration for the patient.

Full details of the dose selected

Non-administration reasons may be recorded

When recording administration, the current date and time defaults in but can be over-ridden

The updated administration record confirming that the erythromycin has been administered

An intravenous infusion is selected for administration

Entering the batch number and expiry date

Entering password of second checker (if required)

Batch number and second check confirmed

Heparin infusion now in progress

Administration history desktop

Report for the ward manager of doses overdue on the ward. Used at nursing shift handover

Monitoring ADR

Monitoring

Boring & not performed well by humans

Data collected hard to sift through to detect problems If monitoring of information is computerized, applications can perform this task, looking for relations & trends & highlighting them, which permits clinicians to intervene before an adverse outcome occurs.

Rapid response to & tracking of adverse events

I.T. can be used with electronic medical records to identify, intervene early in, and track the frequency of adverse events Combing clinical data bases to detect signals that suggest the presence of an adverse drug event (e.g. use of an antidote). This approach identified 81x as many events as did spontaneous reporting Classen DC et al. JAMA. 1991;266:28472851
Such tools may be useful both for the improvement of care and for research.

Other ways that I.T. can improve drug safety

Improving communication

Improve exchange of information

Computerized coverage systems for signing out Hand-held personal digital assistants Wireless access to electronic medical records
Especially if links b/w various applications & a common clinical data base are in place

Urgent action

Serious laboratory abnormalities: hypokalemia Require urgent action when clinician is not around Such results can be lost amid less critical data.
Information systems: identify & rapidly communicate these problems to clinicians automatically This approach reduced the time to the administration of appropriate treatment by 11% & reduced the duration of dangerous conditions in patients by 29%
Kuperman GJ et al. J Am Med Inform Assoc 1999;6:512-522

Corollary orders

Corollary orders
An action may imply that another should be taken

Prescribing bed rest would trigger the suggestion of initiating prophylaxis against deep venous thrombosis Targets errors of omission Resulted in a change in behavior in 46% vs 22% of the intervention & control group, respectively, with regard to a broad range of actions
Overhage JM, et al. J Am Med Inform Assoc 1997;4:364-375

Barriers to the use of I.T.

Financial barriers

Investment costs can be high

Doolan DF & Bates DW. Health Aff (Millwood) 2002;21:180-188.

Lack of standards

Quality of the decision support remains highly variable

Metzger J & Turisco F. (Accessed 8 Sept, 2010, at http://www.leapfroggroup.org/CPOE/CPOE%20Guide.pdf.)

Lack a single standard for clinical data, procedures, medications, laboratory data
Most applications do not communicate well, w/in organizations, & costs of interfaces are high Some important types of data are privately held.

Personnel barriers

Paradigm shift of the older generation

Cultural values of I.T. being impersonal

Summary

Although I.T. has been used widely in hospitals, relatively few data are available regarding their impact on the safety of the process of giving drugs Exceptions: electronic prescribing & decision support: which have been found to improve drug safety
Robots to fill prescriptions, bar-coding, automated dispensing devices, and computerisation of the medication administration record, though less studied, should all eventually reduce error rates

Thank you