The

Role
of
Technology
in
the
Medication-Use
Process
Introduction
Due to the numerous steps required in the care of patients, the healthcare industry is an
inherently error-prone process that is fraught with opportunities for mistakes to occur. The
healthcare industry must place safety as the national priority and work diligently toward this
goal.
Technology and Healthcare
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. But even as improving technology 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 on 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.
1995
There were television and newspaper accounts that reported that 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.
1997
According to a 1994 American Medical Association report, medication errors related to the
misinterpretation of physicians prescriptions were the second most prevalent expensive
claim listed on malpractice cases filed over a 7-year period on 90,000 malpractice claims
between 1985 and 1992 (Cabral JDT, 1997).
February 25, 2004
While CPOE technology purchases seemed to have plateaued, interest in the bar coding
technology has dramatically increased due to the Federal Drug Agencys (FDA) ruling, which
requires medications to have machine-readable bar coding.
Computerized Prescriber Order Entry (CPOE)
Health Care practitioners still communicate information in the old fashioned way. 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 include accessing patient information spread across multiple
organizations that may be unavailable, especially in large organizations and, therefore,
medical care would be provided without pertinent patient information.
There are also many barriers that lead to ineffective communication to medication orders
that include issues with illegible handwriting, use of dangerous abbreviations and dose
designations, and verbal and faxed orders. Illegible hand-writing 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 (Brodell, 1993; Cabral, 1997; ASHP, 1993). Illegible orders
may also lead to delays in the administration of medications.
The use of 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 transmit those orders electronically to the appropriate
department (AHA, 2000).
CPOE systems offer many other advantages over the traditional paper-based system:

They can improve quality, patient outcomes, and safety by a variety of factors

Identifying patients needing updated immunizations or vaccinations, and suggesting

cancer screening and diagnosis reminders and prompts.

Reduction in the variation in care to improve disease management by improving

follow-up of newly diagnosed condition.

Reminder systems to improve patient management

Automating evidence-based protocol

Adhering to clinical guidelines, or providing screening instrument to help diagnosis

disorder.
Currently, the cost of providing health care is rising while reimbursement of services is
declining. CPOE systems offer a variety of solutions to help reduce the cost of providing
health care and making more appropriate utilization of services:
1.
Reduction of hospitalization and decreased length of stay can be obtained from
automated scheduling of follow-up appointments to reducing unnecessary diagnostic test.
2.
Better use of formulary and generis drugs by providing feedback of prescribing
charges and patterns to encourage prescribers to substitute generics medications for more
expensive branded medications.
3.
Properly designed systems can show improvement in work flow and time saving
measures for prescribers
4.
Savings related to the storage of paper medical records could be substantial,
compared to the costs of storing computerized backup storage devices.
5.
Entering medication and diagnostic orders into a computer system would allow for
instantaneous capturing of charges and therefore enhancing revenue.

6.
Cost associated with the used of transcription notes would be eliminated as well by
using electronic patient record system
7.

There is a patient and user satisfaction.

CPOE systems have demonstrated a reduction in ADEs. Unfortunately, unsafe prescribing

practices and medication errors are still possible with these systems.
Errors in monitoring patients response to therapy can occur if the laboratory system is not
interfaced with medication order entry system.
It is important to have the ability to access past patient history, particularly previous AEDs
and co-morbid conditions, yet some systems are unable to access prior patient care
encounters. Problems may arise if drug information updates are not reformed on a timely
basis or if this information is difficult to access.
Medication errors such as wrong patient error, when the wrong patient is selected from a
menu list of similar patient names; wrong drug errors, when the wrong medication is
selected from a list due to look-alike similarity in either brand or generic name or orders
intended for laboratory levels that are filled as medications can occur.
CPOE systems will affect or even change the work of nurses in many ways, both negative
and positive (AHA, 2000). First, like prescribers, these systems will require nurses to possess
basic computer skills.
Bar Code-Enabled Point-of-Care Technology
Nurses play a vital role in the medication-use process, ranging from their involvement in the
communication of medication orders to the administration of medications. One study
showed that 38% of medication errors occur during the drug administration process (Leape
et al, 1995).
For more than 20 years bar code technology has clearly demonstrated its power to greatly
improve productivity and accuracy in the identification of products in a variety of business
settings, such as supermarkets and department stores proven to be an effective technology,
it quickly spread to virtually all other industries.
Additional levels of functionality can include some of the ff. features:

Up-to-date drug reference information from online medication libraries

Customizable comments or alerts

Monitoring the pharmacy and the nurses response to predetermined rules

Reconciliation for pending or STAT orders

Capturing data for the purpose of retrospective analysis of aggregate data to monitor
trends

Verifying blood transfusion and laboratory specimen collection identification

Negative effects include the following:


Nurses are sometimes caught off guard by the programmed automated actions taken
by the BPOC software

The BPOC seem 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

Nurses felt that their main priority was the timeliness of the medication administration
because BPOC required nurses to type in an explanation when medication even a few
minutes late

Nurses used strategies to increase efficiency that circumvented the intended use of the
BPOC

The use of BPOC systems can possibly introduce new types of medication errors such as the
following:

Omissions

Extra dose

Wrong drug

Wrong dose

Unauthorized drug

Charting errors

Wrong dosage form

Automated Dispensing Cabinet

Traditionally, hospital pharmacies provided medications for patients by filling patient-specific
bins for 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 require staff to enter a unique logon and password to access the system using a
touch screen monitor or by using fingerprint identification.
The rationales behind the wide acceptance of this technology are the following:

Improving pharmacy productivity

Improving nursing productivity

Reducing costs

Improving charge capture

Enhancing patient quality and safety

Some documented unsafe practices with the use of devices include:

The lack of pharmacy screening of medication order prior to administration

Choosing of the wrong medication from an alphabetic pick list

High alert medications placed, stored, and returned to ADCs

Storage of medications with look-alike names and/or packaging

The development of workarounds

Regardless of an organizations steps to purchase or implement ADCs, the following issues

should be considered to ensure safe medication practices:

Consider purchasing a system that allow for patient profiling so pharmacists can enter
and screen drug orders prior to their removal and administration

Carefully select the drugs that will be stocked in the cabinets

Place drugs that cannot be accessed without pharmacy order entry and screening
individual matrix bins

Use individual cabinets to separate pediatric and adult medications

Periodically reassess the drugs stocked in each unit-based cabinet

Remove only a single dose of the medication ordered

Develop a check system to assure accurate stocking of the cabinets

Place allergy reminders for specific drugs on the cabinets

Routinely run and analyze override reports to help track and identify problems

Implementation of Technology
Implementing any form of technology into a healthcare organization can be an imposing
task. The multidisciplinary team will need to address the following issues:

Outlining goals for the type of automation to be implemented

Developing a wish list of desired features and determining which one, given budgetary
constraints, are practical

Investigating systems that are presently available

Analyzing the current workflow and determining what charges are needed

Identify the required capabilities and configuration of the new system

Sell the benefits and objectives of automation to staff

Development of an implementation plan and set realistic timeframe expectations

Conclusion
As patient advocates, nurses have a responsibility to discuss their patient safety concern
and speak up about the dangers associated with the current paper-based medication-used
process. We also have the responsibility to become familiar with the availability of safety
technology, the advantages and disadvantages, to work in collaboration with other
healthcare stakeholders in the search for new and innovative technological solutions to
improve patient safety.