Medication errors are one of the leading causes of injury to hospitalized patients.1 Nurses and pharmacists work together to reduce these errors by evaluating workflow and implementing clinical applications and medication management procedures that improve patient outcomes. A multidisciplinary approach is necessary to design and integrate systems that adequately meet the needs of the entire healthcare team.
The medication-use process is especially prone to errors due to the large number of drugs available and multiple look-alike and sound-alike drug names.2 Electronic medication order entry compounds the problem by creating new hazards through inadvertent keystrokes, or missed menu selections. A study performed at two large tertiary care centers estimated that 2 out of every 100 admissions experience a preventable adverse drug event (ADE).3 Several national organizations are working on initiatives to reduce medication errors, including the Leapfrog Group, the National Quality Forum, and the Joint Commission.
Through an initiative called Transforming Care at the Bedside (TCAB), the Institute for Healthcare Improvement (IHI) and Robert Wood Johnson Foundation created a framework for change in medical/surgical units built around improvements in four main categories:
1. safety and reliability
2. care team vitality
3. patient-centeredness
4. increased value.
The TCAB goal for safety and reliability is that care for patients who are hospitalized is safe, reliable, effective, and equitable. A number of best practices have been demonstrated to improve reliability and help prevent system failures in medical/surgical units. Included in such practices are medication system redesign, which can yield dramatic improvements. One example from the IHI effort comes from Iowa Health System (IHS). Working in a positive culture of safety and nonpunitive error reporting, IHS reduced adverse drug events across its entire system of 10 hospitals by 15 percentage points (a 65% reduction) in a 6-month period.4
The pharmacist's role
Recognizing the rapidly increasing role of the pharmacist in the use of healthcare information systems, the Healthcare Information and Management Systems Society (HIMSS) established the Pharmacy Informatics Community in 2006. The purpose of this emerging community is to "enhance pharmaceutical care by bringing measurable improvements in the medication-use cycle to healthcare professionals and the patients they serve through the study, design, and implementation of information technology systems."5 One of the primary goals of the Pharmacy Informatics Community is to improve the quality of pharmacy and medication-management systems and to serve as advocates for quality and efficiency improvements via pharmacy informatics.
The American Society of Health-System Pharmacists (ASHP) has developed a position statement that encourages pharmacists "to use their knowledge of information systems and the medication-use process to improve patient care by ensuring that new technologies lead to safer and more effective medication use."6 Pharmacy informaticists are well suited to lead projects such as computerized provider order entry (CPOE) systems that are integrated with pharmacy information systems; clinical decision support systems (CDSS) that include rule-based systems for medication-related events and information; pharmacy information systems that include order entry, supply-chain management, and revenue compliance; automated dispensing cabinets and robotics; and integrated medication administration management systems such as bar-coded medications and use of smart infusion pumps. While pharmacists have a body of knowledge about the safe and effective use of medications, their participation in the design and implementation of medication-use systems must be collaborative and comprehensive across the entire healthcare organization.
Participative focus
Medication reconciliation is a key focus area for patient safety that can benefit from collaboration between nurses and pharmacists. Medication reconciliation is defined as "a process for obtaining and documenting a complete and accurate list of a patient's current medications upon admission and comparing this list to the physician' admission, transfer, and/or discharge orders to identify and resolve discrepancies."7 The Illinois Hospital Association Patient Safety Learning Collaborative on Medication has outlined five easy steps to follow:
1. Develop a list of current medications, including herbals, supplements, and over-the-counter drugs.
2. Compare this list to medications ordered upon admission, transfer, and discharge.
3. Identify discrepancies (dose, route, or frequency), duplications, omissions, and contraindications.
4. Resolve discrepancies.
5. Communicate the new list upon transfer and discharge to appropriate caregivers and patient.
However, designing a system that ensures each of these steps happens every time is quite challenging. Involving pharmacists early in this process is critical for success. A multidisciplinary strategy is necessary to reconcile medications across the care continuum. Pharmacists have expertise and experience with medication histories and are familiar with drug names, characteristics, effects, and dosage forms. They can identify inconsistencies and mistakes in patients' self-reported medication histories, and are familiar with non-prescription and herbal preps. Recent research has shown that pharmacists improve medication safety, accuracy and efficiency of medication reconciliation, medication adherence, patient medication knowledge, and allergy information and documentation.8
The TIGER initiative seeks to better prepare practicing nurses and nursing students to use technology and informatics to improve patient care delivery.9 Establishing collaborative connections with other disciplines is an important part of the initiative. To reach the 10-year vision of evidence and informatics transforming nursing, the profession must take an active role in the design and integration of informatics tools that are intuitive, affordable, useable, responsive, and evidence-based. Nursing also must create tools that serve nurses and other professionals as members of multidisciplinary care teams.
Designing safety into systems
One of the drivers for electronic medication order entry systems -including CPOE and electronic prescribing systems-is their ability to prevent errors by eliminating illegible handwriting and alerting providers about potential contraindications or duplicate orders. However, recent literature has introduced the concept of "e-iatrogenesis" to describe unintended consequences associated with electronic medication order entry systems.2 The HIMSS Pharmacy Informatics Task Force recommends the inclusion of inherent safety as a key principle guiding system design in order to realize the potential safety gains from CPOE and e-prescribing. Inherent safety results from design decisions that absolutely prevent the possibility of certain hazards or errors.
Clinical decision support systems typically provide alerts triggered by evidence-based rules to actively warn the user when order elements are unsafe. The passive nature of inherent safety uses similar rules, but it's designed to work behind the scenes, eliminating the possibility of specific errors, while saving valuable clinician time in responding to alerts and reminders. Examples include the use of on-screen digital pictures to identify patients and displaying the most recent electrolyte values when electrolytes are being ordered.
Use of bar code point of care (BPOC) systems is another method for preventing medication administration errors that's best planned and implemented by a multidisciplinary team. Up to 38% of inpatient medication errors occur at the administration stage.10 A process for design of these systems should begin by starting with the desired outcomes.11 An ideal BPOC system should:
* permit interoperability between disparate systems
* permit dose verification irrespective of the products used to fill the order
* permit provider order entry that doesn't require the provider to know how the dose will be supplied by the pharmacy
* require a change to the medication order only when there's a change in clinical intent
* offer an encoded standard that permits specification of the variety of medication fulfillment options
* support the acquisition of encoded information from a variety of sources.12
A system with these capabilities will benefit nurses, pharmacists, and patients because the system is doing what it intended to do, eliminating errors before they occur.
Medication management trends
Chartered in 2005, the American Health Information Community (AHIC) makes recommendations on how to accelerate the development and adoption of health information technology (IT). This focus is designed to advance efforts to achieve President Bush's goal for most Americans to have access to secure electronic health records by 2014.13 In January 2007, the AHIC approved a recommendation to develop a Use Case addressing medication management. Intended to facilitate access to necessary medication and allergy information for both providers and consumers when healthcare is sought and delivered, the Medication Management Use Case has the potential to improve medication management through increased information exchange across the care continuum.
Nurses and pharmacists, key stakeholders in this effort, are providing their expertise to the Care Delivery Technical Committee of the Healthcare Information Technology Standards Panel that's working on selecting the appropriate standards and writing the specifications. Federal health agencies and health IT vendors and suppliers will begin implementing these specifications into products beginning in 2008.
According to several recent surveys, systems that can enable improvements in patient safety are a major focus of current implementations in healthcare organizations. Nearly 50% of the 776 nursing informaticists who responded to the HIMSS 2007 Nursing Informatics Survey reported that they're currently developing or implementing electronic medication administration records systems. Another 34% of respondents identified bar-coded medication management systems as being in development or in the process of implementation.14
The number one IT priority of chief information officers responding to the 18th Annual HIMSS Leadership Survey is reducing medical errors and promoting patient safety.15 In terms of technology adoption, bar coding is the top technology that survey respondents intend to implement in the next 2 years.
With the large number of clinical systems currently being planned and implemented, it's no surprise that the number one staffing need identified by nearly one-third of respondents is for clinical informaticists. Clinical transformation and clinical champions were also frequently noted in future staffing needs. Ten percent of respondents also identified a lack of time and commitment from clinicians as a significant barrier to successfully implementing IT.
Collaboration promotes compliance
A 2006 national survey performed by the ASHP focused on whether hospitals met the national patient safety goals for medication reconciliation. Nearly three-quarters of the surveyed hospitals met the goal, but 34% identified lack of pharmacy resources as a barrier, and 5% viewed the problem as a nursing responsibility.16
An interdisciplinary process is needed that includes input from emergency department, operating room, admission, nursing, pharmacy, physician, risk management, quality improvement, and IT representatives. Buy-in and support from organizational and clinical leadership are also keys to success.17 Using a multidisciplinary approach for inpatient medication reconciliation in an academic setting led to a 50% decrease in serious and life-threatening medication reconciliation errors.18
Integrated clinical information systems can significantly impact medication errors throughout the medication-use process.19 Implementation of CPOE and CDSS in a multi-hospital setting demonstrated a significant effect on reducing error rates for three of the four indicators measured: drug allergy detection, excessive dose, and incomplete or unclear order. Order turnaround of medication and its availability in the unit decreased from an average of 90 to 11 minutes, an 88% reduction, after implementation of a pharmacy information system and CPOE interface, along with an electronic drug-dispensing system.
Electronic medical record (EMR) system investments can be hard to justify based on straight return-on-investment calculations.1 However, recent analysis has shown that sophisticated EMR technologies can lead to improved patient outcomes.20 Interestingly, the key integrated automations that help to prevent or eliminate medical errors are systems shared by nurses and pharmacists: CPOE, pharmacy dispensing, and nursing medication administration. However, these very systems used in combination to achieve closed-loop medication administration are installed in less than 1% of U.S. hospitals. After installation of an EMR system at Ohio State University Health System, medication turnaround times dropped 64%; radiology order entry turnaround times fell from 7 hours, 37 minutes, to 4 hours, 21 minutes; and medical transcription errors were eliminated.21
Certainly not all outcomes of clinical system installations are positive. Recent studies have shown that there can be unanticipated and even undesired consequences of healthcare IT implementations.22 Clinicians, including nurses and pharmacists, frequently blame these unintended consequences and implementation failures on the newly implemented systems. However, the impact of IT on workflow, culture, and social interaction may also be a cause of the problem. One example includes the persistent use of paper as a consequence of inadequate integration of the new technology with existing systems. A poor fit between new health IT and existing technical and physical infrastructures is also a common problem.
Recognizing the complexity of medication management system implementations and anticipating user-resistance across the spectrum of care delivery are important indicators of success. Nurses and pharmacists should maximize their partnership by taking a multidisciplinary approach to address potential negative impacts of medication management systems and work together to realize their full potential for improving patient safety, quality, and efficiency.
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