Electronic Medication Management System Research Articles

Writing and dispensing safe prescriptions

Writing and dispensing safe prescriptions

Doctor-pharmacist communication in hospitals: strategies, perceptions, limitations and opportunities.

Frequency of use of communication methods, perceptions of the convenience, time taken to use, accuracy and effectiveness of each method. Results More than 95% of doctors and pharmacists combined used face-to-face and phone calls to communicate with each other, 70% used a medication management plan, and 62% used progress notes. A preference for oral communication was confirmed with the expressed need for building professional rapport and receiving responses. Perceptions regarding effectiveness of oral communication methods were related to perceptions of their convenience and accuracy. Professional groups described differences in perceived ownership of various modes of communication. Conclusions Preferences for oral communication create potential issues with recall and comprehension. Integrating oral communication features into written communication methods, e.g. creating responses, conversations, building rapport, may change doctors' and pharmacists' perceptions of effectiveness. Communication receipt and response functionality in electronic medication and record management systems may improve communication.

Nursing Satisfaction with Medication Care by Using Neonatal Electronic Medication Management Systems

Background: Medication management is a complex process with multiple stages that involves different health care teams. Based on the evidence, an electronic medication management system offers significant benefits, such as reduced medication errors, improved conformity, enhanced time and cost efficiency, and increased patient safety. This study aimed to design and implement an electronic medication management system and measure the nurse’s satisfaction regarding the application of this system. Methods: In this technical action research, the nurses' satisfaction with the use of the designed system was evaluated. The electronic medication system development and data collection were conducted in two phases. The first phase included the design and development of an electronic nursing medication management system to be used in the neonatal intensive care unit. The second phase involved the evaluation of the nurses’ satisfaction with the use of the electronic system by applying a five-point Likert scale questionnaire. Results: The findings were divided into two categories, including results related to the design of the electronic systems and those regarding the evaluation of nurses’ satisfaction with the use of the electronic systems. The design of the electronic system was successful as the nurse's satisfaction evaluation revealed a high level of satisfaction with the use of the system. Conclusion: Electronic medication management system has more practical advantages than other similar systems. This system helps the nurses to identify and prevent many medication errors and save time in drug care documentation. Therefore, this system is a big step towards satisfaction with nursing medication care.

What do Australian consumers, pharmacists and prescribers think about documenting indications on prescriptions and dispensed medicines labels?: A qualitative study

BackgroundDocumenting the indication on prescriptions and dispensed medicines labels is not standard practice in Australia. However, previous studies that have focused on the content and design of dispensed medicines labels, have suggested including the indication as a safety measure. The aim of this study was to investigate the perspectives of Australian consumers, pharmacists and prescribers on documenting the indication on prescriptions and dispensed medicines labels.MethodsSemi-structured interviews were conducted and mock-up of dispensed medicines labels were designed for participants. Consumers (n = 19) and pharmacists (n = 7) were recruited by convenience sample at community pharmacies in Sydney (Australia) and prescribers (n = 8), including two medical students, were recruited through snowballing.ResultsThirty-four participants were interviewed. Most participants agreed that documenting the indication would be beneficial especially for patients who are forgetful or take multiple medications. Participants also believed it would improve consumers’ medication understanding and adherence. Prescribers and pharmacists believed it could help reduce prescribing and dispensing errors by matching the drug/dosage to the correct indication. Prescribers refrained from documenting the indication to protect patients’ privacy; however, most patients did not consider documenting the indication as a breach of privacy. Prescribers raised concerns about the extra time to include indications on prescriptions and best language to document indications, using plain language as opposed to medical terminology.ConclusionsAll interviewed stakeholders identified numerous benefits of documenting the indication on prescriptions and dispensed medicines labels. Whether these potential benefits can be realized remains unknown and addressing prescribers’ concern regarding the time involved in documenting the indication on prescriptions remains a challenge for vendors of electronic medication management systems.

The Precise Observation System for the Safe Use of Medicines (POSSUM): An Approach for Studying Medication Administration Errors in the Field.

Medication administration errors (MAEs) in hospital are frequent and significantly more likely to result in serious harm to patients than other medication error types. Many interventions have been proposed in order reduce MAEs and the amount of harm associated with these errors. A major limitation in assessing the effectiveness of these interventions has been the lack of robust measures for assessing changes in MAEs and associated harms. Drawing upon extensive foundational research we have developed a robust approach and data collection software to be applied in direct observational studies of nurses to allow measurement of changes in MAE rates. We report how this approach is being applied in a large stepped-wedge cluster randomised controlled trial to assess the effectiveness of an electronic medication management system to reduce MAEs in a paediatric hospital.

Staff experience and perceptions of the safety and risks of electronic medication management systems in Victorian public hospitals

AbstractBackgroundVictorian hospitals are at various stages of transition to electronic medication management system (EMMS). Although improvements in medication safety and error reduction are assumed when using an EMMS, concerns have been raised regarding potential unintended consequences and possible new error types, so information from frontline staff using EMMSs provides an insight into their safety and some of the risks associated with their use.AimThe aims of this study were to determine the perceptions of frontline staff using an EMMS regarding the safety of the EMMS and the potential for new errors or those errors that were more likely with the use of an EMMS, and providing this feedback to the participating organisations.MethodFrontline clinical staff in eight Victorian hospitals using EMMS were invited to participate in voluntary, anonymous online survey designed and analysed by experienced medication safety pharmacists.ResultsRespondents (n = 664) included medical officers (30%) nurses (49%) and pharmacists (16%). Forty‐eight percent of respondents have observed, investigated or reviewed errors/near misses in EMMS. Fifty‐six percent believe that these errors/near misses are a new type of error related to EMMS. Top issues identified by those involved in an error (195) were incorrect patient selection and incorrect dose scheduling, resulting in dose duplication. Fifty‐six percent agree or strongly agree that EMMS has reduced the potential for medication errors and 58% consider that EMMS has introduced new types of errors. The most significant issues raised about EMMS were time‐consuming and non‐intuitive processes and overdependence on technology.ConclusionStaff experience and perception of EMMS was overall positive, most considering that medication error risk is reduced, but safety concerns remain to be addressed.

Applying the Theoretical Domains Framework to identify barriers and targeted interventions to enhance nurses\u2019 use of electronic medication management systems in two Australian hospitals

BackgroundMedication errors harm hospitalised patients and increase health care costs. Electronic Medication Management Systems (EMMS) have been shown to reduce medication errors. However, nurses do not always use EMMS as intended, largely because implementation of such patient safety strategies requires clinicians to change their existing practices, routines and behaviour. This study uses the Theoretical Domains Framework (TDF) to identify barriers and targeted interventions to enhance nurses’ appropriate use of EMMS in two Australian hospitals.MethodsThis qualitative study draws on in-depth interviews with 19 acute care nurses who used EMMS. A convenience sampling approach was used. Nurses working on the study units (N = 6) in two hospitals were invited to participate if available during the data collection period. Interviews inductively explored nurses’ experiences of using EMMS (step 1). Data were analysed using the TDF to identify theory-derived barriers to nurses’ appropriate use of EMMS (step 2). Relevant behaviour change techniques (BCTs) were identified to overcome key barriers to using EMMS (step 3) followed by the identification of potential literature-informed targeted intervention strategies to operationalise the identified BCTs (step 4).ResultsBarriers to nurses’ use of EMMS in acute care were represented by nine domains of the TDF. Two closely linked domains emerged as major barriers to EMMS use: Environmental Context and Resources (availability and properties of computers on wheels (COWs); technology characteristics; specific contexts; competing demands and time pressure) and Social/Professional Role and Identity (conflict between using EMMS appropriately and executing behaviours critical to nurses’ professional role and identity).The study identified three potential BCTs to address the Environmental Context and Resources domain barrier: adding objects to the environment; restructuring the physical environment; and prompts and cues. Seven BCTs to address Social/Professional Role and Identity were identified: social process of encouragement; pressure or support; information about others’ approval; incompatible beliefs; identification of self as role model; framing/reframing; social comparison; and demonstration of behaviour. It proposes several targeted interventions to deliver these BCTs.ConclusionsThe TDF provides a useful approach to identify barriers to nurses’ prescribed use of EMMS, and can inform the design of targeted theory-based interventions to improve EMMS implementation.

Pharmacist-led admission medication reconciliation before and after the implementation of an electronic medication management system

AimsTo investigate the impact of the introduction of an electronic medication management system on the proportion of patients with a recorded medication reconciliation on admission, the time from admission to when medication reconciliation was performed, and the characteristics of patients receiving this intervention pre-and post-implementation. MethodsAn electronic medication management system was implemented in an Australian hospital from May to July 2015. A retrospective observational study was conducted in three wards across two phases; pre- (August 2014) and post- (August 2015) implementation. The study sample included every second patient admitted to these wards. ResultsA total of 370 patients were included, 179 pre- and 191 post-implementation. The proportion of recorded admission medication reconciliation significantly increased post-implementation in all study wards; coronary care unit (40 vs 68%, p=0.004), gastroenterology ward (39 vs 59%, p=0.015), and the neurology ward (19 vs 45%, p=0.002). The proportion of patients with recorded medication reconciliation within 24h of weekday admissions, or 48–72h of weekend admissions, increased from 47% pre- to 84% post-implementation. Admission medication reconciliation was recorded within a median of 1.0day for weekday admissions pre- and post-implementation (IQR 1.1 vs 0.2, respectively), and 3.5days (IQR 2.0) pre-implementation vs 1.5days (IQR 2.0) post-implementation for weekend admissions. Overall, across both phases pre-and post-implementation, admission medication reconciliation was recorded for patients who were significantly older (median 77 and 71 years, p<0.001), had a higher number of preadmission medications (median 6.5 and 5.0 medicines, p=0.001), and had a longer hospital stay (median 6.5 and 5.1days, p=0.003). A significantly higher proportion of patients with recorded medication reconciliation in the pre-implementation phase experienced polypharmacy (61%, p=0.002), hyperpolypharmacy (15%, p=0.001), and used a high-risk medication (44%, p=0.007). ConclusionsImplementing an electronic medication management system facilitates the medication reconciliation process leading to more high risk patients receiving this service on admission to hospital and in a more timely manner. The impact of electronic medication reconciliation on patient safety and clinical outcomes remains unknown.

Little Things Matter: A Time and Motion Study of Pharmacists' Activities in a Paediatric Hospital.

How healthcare providers distribute their time can impact on the quality and safety of care delivered, and this has been widely studied in hospitals providing care to adult patients. Children are different to adults and the workflow of healthcare providers in paediatric settings is largely unknown. The aim of this study was to quantify how clinical pharmacists working in a paediatric hospital spend their time. A direct observational time and motion study was conducted where two independent observers shadowed seven pharmacists covering eight wards for over 60 hours. Pharmacists spent the majority of time performing medication review (32.6%), followed by communication, non-clinical tasks, supply, medication discussion and in-transit. They were interrupted 3.5 times per hour and spent 4.4% of observed time multi-tasking. This is the first study to quantify how pharmacists in a paediatric hospital distribute their time. These results could act as useful baseline data against which to measure the impact of innovations, such as electronic medication management systems, on pharmacists' workflow.

Applying the National Inpatient Medication Chart audit to electronic medication management systems: what does it tell us?

AbstractThe Australian Commission on Safety and Quality in Health Care (ACSQHC) coordinates nation‐wide audits of the National Inpatient Medication Chart (NIMC). Electronic Medication Management Systems (eMMS) are beginning to replace NIMCs in Australian hospitals. This article describes the NIMC audit experience in two Australian tertiary hospitals that have established eMMS. Medication charts at both hospitals were audited using the ACSQHC‐provided audit tools (2012 Version). At both hospitals, eMMS charts exhibited higher levels of compliance with audit criteria than NIMCs, except for documentation of indication for medication. With eMMS, both hospitals exceeded national averages on many audited parameters, with the exceptions of documentation of weight and indication for medication. eMMS produces clearer, more complete medication orders and patient information, which may improve quality and safety of prescribing and reduce medication errors. Feedback was provided to the ACSQHC regarding aspects of the NIMC audit that did not align with eMMS for consideration in future audits.

Medication Safety: Experiential Learning for Pharmacy Students and Staff in a Hospital Setting.

Medication Safety has been an established pharmacy specialty in Australian hospitals since the early 2000s and is now one of the ten Australian hospital accreditation standards. Although advances have occurred, medication-related patient harm has not been eradicated. Victorian undergraduate pharmacy programs include some aspects of medication safety, however clinical pharmacy experience, along with interpersonal and project management skills, are required to prepare pharmacists to be confident medication safety practitioners. This article outlines the range of medication safety-related training offered at an Australian tertiary teaching hospital, including; on-site tutorial for undergraduate students, experiential placement for pharmacy interns, orientation for pharmacy staff and resources for credentialing pharmacists for extended roles. Improvements continue to be made, such as electronic medication management systems, which increase the safe use of medications and facilitate patient care. Implementation and evaluation of these systems require medication safety expertise. Patients’ engaging in their own care is an acknowledged safety improvement strategy and is enhanced by pharmacist facilitation. Building educator skills and integrating experiential teaching with university curricula should ensure pharmacists have both the knowledge and experience early in their careers, in order to have a leading role in future medication management.

Stepped-wedge cluster randomised controlled trial to assess the effectiveness of an electronic medication management system to reduce medication errors, adverse drug events and average length of stay at two paediatric hospitals: a study protocol

IntroductionMedication errors are the most frequent cause of preventable harm in hospitals. Medication management in paediatric patients is particularly complex and consequently potential for harms are greater than in adults....

ISQUA16-2346A COLLABORATIVE CROSS-COUNTRY STUDY TO MEASURE THE IMPACT OF ELECTRONIC MEDICATION MANAGEMENT SYSTEMS: Table 1

Internationally, countries are investing in electronic medication management (eMMS; also known as CPOE/ePrescribing) systems to improve medication safety. These organisational-wide interventions impact the work of all involved in the medication pathway and can significantly impact workflows. Hospital pharmacists’ work is particularly likely to be affected, yet little research has attempted to quantify the nature of these changes, or their impact on medication service efficiency or safety. Cross-country research in health informatics is rare. As a result, many small-scale studies are replicated in different locations. Variations in methods and outcomes, …

Medication Safety

Medication Safety

Electronic Prescribing and Medication Management at a Residential Aged Care Facility: Uptake by General Practitioners and Qualitative Evaluation of the Benefits and Barriers.

A cloud-based mobile electronic prescribing and medication management system (ePMMS), in which prescribers' orders directly populate residential aged care facility (RACF) medication administration records (MARs) and are communicated electronically to the RACF's pharmacy, may create efficiencies and improve patient safety when compared to the paper-based and hybrid paper-electronic medication management systems used in most Australian RACFs. Little is known about general-practitioners' (GPs'), nurses' and pharmacists' acceptance of, or experiences with, ePMMS. To explore the uptake of an ePMMS by GPs, and the experiences and perceptions of GPs, nurses and pharmacists, at a 90-bed RACF that tested a beta-version ePMMS. Retrospective audit to determine the proportion of medicines ordered by GPs via the ePMMS over a three-month period. Focus groups conducted three-to-four months after implementation: one with GPs (n=5), one with nurses (n=12); in-depth interview/survey of pharmacists (n=2). Qualitative data were analysed thematically. Three of seven GPs used the ePMMS to order medicines; 53/205(25.9%) medicines were ordered via the ePMMS by GPs. Two broad themes were identified: benefits of the ePMMS, and barriers/limitations. Benefits related to patient safety and workforce efficiency, and included GPs' ability to access and modify residents' MARs remotely, no need for nurses to fax orders to the pharmacy, and no need for pharmacy transcription of GPs' handwritten orders to create electronic MARs. Barriers and limitations related to inefficiency, low GP uptake and training/support, and included slower prescribing compared to written orders, the need for GP-signed paper copies of the MAR, lack of integration with GP clinic software, and low GP motivation to use the system, especially GPs with few patients at the RACF. GPs, nurses and pharmacists felt the ePMMS improved medication-safety and workforce-efficiency, however a number of barriers were identified that contributed to low GP-uptake and limited the benefits.

Positioning a Paediatric Compounded Non-Sterile Product Electronic Repository (pCNPeRx) within the Health Information Technology Infrastructure.

Numerous gaps in the current medication use system impede complete transmission of electronically identifiable and standardized extemporaneous formulations as well as a uniform approach to medication therapy management (MTM) for paediatric patients. The Pharmacy Health Information Technology Collaborative (Pharmacy HIT) identified six components that may have direct importance for pharmacy related to medication use in children. This paper will discuss key positions within the information technology infrastructure (HIT) where an electronic repository for the medication management of paediatric patients’ compounded non-sterile products (pCNP) and care provision could be housed optimally to facilitate and maintain transmission of e-prescriptions (eRx) from initiation to fulfillment. Further, the paper will propose key placement requirements to provide for maximal interoperability of electronic medication management systems to minimize disruptions across the continuum of care.

Evaluation of a hybrid paper-electronic medication management system at a residential aged care facility.

Objectives The aims of the study were to investigate discrepancies between general practitioners' paper medication orders and pharmacy-prepared electronic medication administration charts, back-up paper charts and dose-administration aids, as well as delays between prescribing, charting and administration, at a 90-bed residential aged care facility that used a hybrid paper-electronic medication management system. Methods A cross-sectional audit of medication orders, medication charts and dose-administration aids was performed to identify discrepancies. In addition, a retrospective audit was performed of delays between prescribing and availability of an updated electronic medication administration chart. Medication administration records were reviewed retrospectively to determine whether discrepancies and delays led to medication administration errors. Results Medication records for 88 residents (mean age 86 years) were audited. Residents were prescribed a median of eight regular medicines (interquartile range 5-12). One hundred and twenty-five discrepancies were identified. Forty-seven discrepancies, affecting 21 (24%) residents, led to a medication administration error. The most common discrepancies were medicine omission (44.0%) and extra medicine (19.2%). Delays from when medicines were prescribed to when they appeared on the electronic medication administration chart ranged from 18min to 98h. On nine occasions (for 10% of residents) the delay contributed to missed doses, usually antibiotics. Conclusion Medication discrepancies and delays were common. Improved systems for managing medication orders and charts are needed. What is known about the topic? Hybrid paper-electronic medication management systems, in which prescribers' orders are transcribed into an electronic system by pharmacy technicians and pharmacists to create medication administration charts, are increasingly replacing paper-based medication management systems in Australian residential aged care facilities. The accuracy and safety of these systems has not been studied. What does this paper add? The present study identified discrepancies between general practitioners' orders and pharmacy-prepared electronic medication administration charts, back-up paper medication charts and dose-administration aids, as well as delays between ordering, charting and administering medicines. Discrepancies and delays sometimes led to medication administration errors. What are the implications for practitioners? Facilities that use hybrid systems need to implement robust systems for communicating medication changes to their pharmacy and reconciling prescribers' orders against pharmacy-generated medication charts and dose-administration aids. Fully integrated, paperless medication management systems, in which prescribers' electronic medication orders directly populate an electronic medication administration chart and are automatically communicated to the facility's pharmacy, could improve patient safety.

Cost-effectiveness analysis of a hospital electronic medication management system.

Objective To conduct a cost–effectiveness analysis of a hospital electronic medication management system (eMMS). Methods We compared costs and benefits of paper-based prescribing with a commercial eMMS (CSC MedChart) on one cardiology ward in a major 326-bed teaching hospital, assuming a 15-year time horizon and a health system perspective. The eMMS implementation and operating costs were obtained from the study site. We used data on eMMS effectiveness in reducing potential adverse drug events (ADEs), and potential ADEs intercepted, based on review of 1 202 patient charts before (n = 801) and after (n = 401) eMMS. These were combined with published estimates of actual ADEs and their costs. Results The rate of potential ADEs following eMMS fell from 0.17 per admission to 0.05; a reduction of 71%. The annualized eMMS implementation, maintenance, and operating costs for the cardiology ward were A$61 741 (US$55 296). The estimated reduction in ADEs post eMMS was approximately 80 actual ADEs per year. The reduced costs associated with these ADEs were more than sufficient to offset the costs of the eMMS. Estimated savings resulting from eMMS implementation were A$63–66 (US$56–59) per admission (A$97 740–$102 000 per annum for this ward). Sensitivity analyses demonstrated results were robust when both eMMS effectiveness and costs of actual ADEs were varied substantially. Conclusion The eMMS within this setting was more effective and less expensive than paper-based prescribing. Comparison with the few previous full economic evaluations available suggests a marked improvement in the cost–effectiveness of eMMS, largely driven by increased effectiveness of contemporary eMMs in reducing medication errors.

Human Factors Approach in the Design of an Electronic Medication Management System for Preventing Inpatient Medication Errors

Background: In order to ensure quality and safety of prescriptions, electronic medication management system needs to comply with medication safety requirements and human factors principles. The design of such a system can make the difference on physician acceptance and consequently on medication safety. The aim of the study is to evaluate to what extent the changes in the design of the electronic medication management system may affect the rate of medication errors. Materials and method: In light of the growing development of computerized systems in health services it has become necessary to design electronic medication management system for drug prescription and administration compliant with the requirements of medication safety practices. Prescription data relative to 100 patients admitted to the Cardiothoracic Department of the Gabriele Monasterio Foundation Heart Hospital (FTGM) were extracted from the computerized medical notes from March 2013 until May 2013. The prescriptions examined had been written using the electronic documentation prompt without structured entry fields. All prescriptions were evaluated using the medication safety requirements of the medication safety practice developed by the Centre for Patient Safety of the Regional Department of Health in Tuscany, Italy. The same prescriptions were then simulated using the novel electronic medication management module and reassessed according to the safety requirements. Results: Of the 4112 prescriptions pertaining to the 100 study patients analyzed, 88.5% were found to be erroneous or incomplete. In particular 46.8% did not include the route of administration, 29.4% the pharmaceutical form, 10.6% the number of administrations per day and/or the time of administration, in 8.2% the dose was not defined and 4.9% did not include the active pharmaceutical agent or trade name. 14.9% were considered with high potential for harm. The same prescriptions simulated through the novel electronic module were 99.1% correct and complete. Conclusions: The ergonomic design of the module for electronic prescription meets the medication safety requirements and has a role in reducing drug errors and enhancing the safety of the workflow. The module introduced structured fields pertaining the type of drug being prescribed which were positively embodied in the routine and produced a significant reduction of prescription errors.

Optimising computerised alerts within electronic medication management systems: A synthesis of four years of research.

Most studies evaluating the effect of computerised alerts embedded in electronic medication management systems (eMMS) on prescribing behavior demonstrate positive and often substantial effects. But many studies also report that doctors override computerised alerts, sometimes up to 95% of the time. Alert fatigue, due to excessive numbers of alerts being presented, is the primary reason for alerts being overridden. This paper summarises and sythesises a program of research undertaken to determine whether doctors working in a teaching hospital in Sydney, Australia, were experiencing alert fatigue, and to identify and implement strategies for alleviating alert fatigue. We synthesise several published studies adopting a variety of data collection methods (observation of prescribers as they interact with the eMMS, interviews with users, review of alerts generated in eMMS, and a Delphi technique) to present four key lessons learnt. These are: 1) the fewer alerts the better; 2) context of use matters; 3) people use systems in unexpected ways; and 4) user feedback is invaluable.