ROLE OF TECHNOLOGY IN

MEDICATION USE
PROCESS

Charisse Hazel G. De
Leon, RN
 IMPORTANT FACTS:
 In fact, less than 10% of health care
organizations have yet to incorporate any type
of medication safety technology indicating that
they have allocated their limited financial and
human resources in other directions.
1995 –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 4 days
at the Dana Farber Cancer Institute
 How do we solve the
problems with regard to
medication usage and
administration?
 Solutions to the problem:
IT INNOVATIONS IN MEDICATION
USE PROCESS
• Computerized Prescriber Order
Entry (CPOE)
• Bar Code-enabled point-of-care
technology
• Automated Dispensing Cabinets
• Smart Infusion Pump Delivery
Systems
The Spoonful of Sugar: medicine
management in NHS hospitals (Audit
Commission 2001) report concluded:
• Complications arising from medicines
treatment are the most common cause of
adverse events in hospital patients.
• Errors may occur from the initial decision
to prescribe to the final administration of
the medicine, and these include choice of
the wrong medicine, dose, route, form,
and frequency.
• Prescription sheets themselves may also
be temporarily unavailable or lost.
• 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.
• Handwritten prescriptions are used 99% of the time
to communicate orders.
• Studies have shown that as a result of poor
handwriting, 50% of all written physician orders
require extra time to interpret.
• Illegible handwriting on medication orders has been
shown to be a common cause of prescribing errors
and patient injury and death have actually resulted
from such errors
 COMPUTERIZED
PRESCRIBER ORDER ENTRY
(CPOE)
The Leapfrog Project advocated the
use of CPOE technology to prevent
errors.
 Benefits:
• Increased accessibility to patient
information across multiple organizations
• Standardization of patient’s record,
minimizing illegible handwritten entries
• Improvement of communication among
health care providers and patients
• Improvement of patient outcomes and
safety
- increasing preventive health guideline
compliance by exposing prescribers to
reminder messages
 Benefits:
 Reduction in the variation of care to improve disease
management
- improving follow-up of newly diagnosed conditions,
reminder systems to improve patient management,
automating evidence-based protocols, adhering to
clinical guidelines, or providing screening instruments to
help diagnosis disorders
Improvement of drug prescription and administration
- improving antibiotic usage, suggesting whether certain
antibiotics or their dosages are appropriate for use
 Benefits:
• Medication refill compliance can be increased
- Using reminder system to increase adherence
to therapies
• Improved drug dosaging
• Reduction in ADEs
• *Serious medication errors were reduced by 55%
and preventable ADEs were reduced by 17%
(Bates et al, 1998). Non-missed-dose
medication errors fell from 142/1,000 patient
days to 26.6/1,000 patient days.
 CPOE:
Underlying issues
• High implementation costs
• - Increased need for a fiber-optic backbone network; time,
space, and manpower to provide adequate staff education
and development; and workstations and high-speed
internet access
• Integration of ‘legacy’ systems of the organization in the
implementation of CPOE
• Existence of the possibilities of medication errors
 CPOE:
Underlying issues
• The activation of warning and alerts
during use of CPOE
• - Vendors do not include them in the
package or not programmed for use by
organizations
• Complexity of the system and absence
of interface between laboratory
system and medication order entry
system
 While about half of the ordering, transcribing, and dispensing
errors were intercepted by the nurse before the medication
error reached the patient, almost none of the errors at the
medication administration stage were caught.
Forty three (43%) of hospitals had even discussed the
possibility of bar code drug administration. Two and a half
percent (2.5%) used this technology in some areas of the
hospital. Less than one percent had fully implemented it
throughout the organization (Cohen and Smetzer, 2001).
 Bar Code-enabled point-of-
care technology
 The Department of Veterans Affairs (VA) is one of the first
healthcare facilities to fully adopt bar code technology.
On admission, patients are issued an individualized bar
code wristband that uniquely identifies their identity,
scanned prior to drug administration, verifies the nurse,
patient, and the medication, and electronically record the
administration of the medication in an online MAR
• JCAHO has stated that a bar code with two
unique, patient-specific identifiers will
provide healthcare organizations a system
that complies with the 2004 National
Patient Safety Goal
• During the introduction of the BPOC,
reported medication error rates declined
from 0.02% per dose administered to
0.0025% (Johnson et al, 2002).
• Aim: Improve medication safety through
several functionalities
 FEATURES:
• Increased accountability and capture of
charges for items
• Up-to-date drug reference information from
online medication reference libraries
• Customizable comments or alerts and
reminders of important clinical actions that
need to be taken when administering
certain medications
 FEATURES:
• Monitoring the pharmacy and the nurse’s
response to predetermined rules or
standards in the rules engine
• Reconciliation for pending or STAT orders
• Capturing data for retrospective analysis
of aggregate data to monitor trends
• Verifying blood transfusion and
laboratory specimen collection
 Bpoc:
underlying issues
• Nurses were sometimes caught ‘off guard’ by
the programmed automated actions taken by
the BPOC software
• The BPOC seemed to inhibit the coordination of
patient information between prescribers and
nurses when compared to a traditional paper-
based system.
• Nurses found it more difficult to deviate from
the routine medication administration
sequence with the BPOC system.
 Bpoc:
underlying issues
• Nurses felt that their main priority was the timeliness
of medication administration because BPOC required
nurses to type in an explanation when medications
were given even a few minutes late.
• Nurses used strategies to increase efficiency that
circumvented the intended use of BPOC.
• Pharmaceutical industry’s unwillingness to adopt a
universal bar code standard
 Bpoc:
underlying issues
• Extended lag time between the
launch of new medications and their
availability in unit-dose packaging, as
well as non-bar coded medications
• Possibility of errors:
Wrong drug
Charting errors
Wrong dose
Unauthorized drug
Wrong dosage form
 Automated Dispensing
Cabinets
 An ASHP survey showed that 58% of
hospitals employed technology that totally
redesigned the medication-management
system from the traditional unit-dose
dispensing system to a decentralized
system utilizing ADC on patient care units.

A computerized point-of-use medication-

management system that is designed to
replace or support the traditional unit-dose
drug delivery system; it requires the staff a
unique logon and password to access the
system using a touch screen monitor or by
using finger print identification
 Benefits:
• Improving pharmacy productivity
- reduce number of steps from filling medication bins
to filling a centralized station; reduce time needed
to obtain missing medications
• Improving nursing productivity
- reduce time in obtaining missing medications and
newly ordered medications
• Reducing costs
- reduce inventory and containment costs associated
with expired medications
 Benefits:
• Improving charge capture
- allow capture of all patient charges associated
with administered medications
• Enhancing patient quality and safety
- built-in decision support systems that warn users
on drug-drug interactions, drug-allergy interactions,
drug-lab interactions, drug-drug duplications and so
forth.
• Tracking the storage, dispensing, and use of
controlled substances
 ADC:
UNDERLYING ISSUES
 Lack of pharmacy screening of medication
order prior to administration
Choosing of the wrong medication from an
alphabetic pick list
Use of high-alert medications placed, stored,
and returned to ADCs
- patient injury or death may arise if there is
absence of independent double check from
nurse and from the pharmacy
*High alert medications – medications that, when involved in
medication errors, have a high risk of injury or death
 ADC:
UNDERLYING ISSUES
• Storage of medications with look-alike
names and/or packaging
• - due to confirmation bias
• Development of nurse’s ‘workarounds’
• -when the device does not respond as
expected, nurses will find various ways
of working around the system to obtain
medications
 Smart Infusion Pump Delivery
Systems
• Infusion pumps with dosage-calculation software
used in the administration of parenteral
medications thru IV or epidural lines; medications
are administered based on a calculation of a
volume to be infused per hour of delivery
• Aim: Reduce medication errors, improve workflow,
and provide a new source of data for continuous
quality improvement
 BENEFITS:
• Maximum flexibility, increasing application
to different areas of the hospital
• Applicability of the infusion pump
regardless of patient’s condition, age, and
gender
• Improvement of patient care, minimizing
human memory created errors
 BENEFITS:
 Improvement of drug administration
- Thru comprehensive libraries of drugs, usual concentrations,
dosing units, and dose limits, warnings to exceeded dosage limits,
and configurable settings by patient type or location
Verification of the programming of medication delivery
- Thru prompts and alerts, and setting dosage limits
Eased access to transaction data from the infusion device, leading
to improved patient quality and improved clinical decision-making
 Smart infusion pumps:
underlying issues
• Infusion-device programming errors
• - single wrong entry or button
pressed
• - nurse’s wrong programming of the
dosage
• High implementation costs