Laurence A Goldberg
The impact of IT on clinical services was one of many issues covered. Medication use processes (MUPs) that are 99.9% accurate sound good – but if these figures were translated into other industries in the USA, there would be a major plane crash every three days, 12 babies would be given to the wrong parent each day and there would be 37,000 ATM errors per hour, according to Paul Szumita (Clinical Pharmacy Practice Manager, Brigham and Women’s Hospital, Boston, USA).
Dr Szumita’s hospital has a computerised physician order entry (CPOE) system that was developed in-house, electronic medicines administration records (eMARs), and a pharmacy information system, and also uses smart intravenous pumps. These technologies are essential components of the ideal medication use process, Dr Szumita argued.
The systems at Brigham and Women’s Hospital have been built up over time. Early surveys had shown that 39% of medication errors occurred at the ordering stage, 12% at the transcription stage, 38% during medicines administration and 11% during dispensing.
It was expected that CPOE and barcoding would eliminate many of these errors – and indeed after the introduction of CPOE the overall error rate did fall considerably.
The ideal system is a CPOE setup in which the physician prescribes and makes the entry, which is then approved by a pharmacist. This is linked to an eMAR. This must also interface with the pharmacy system, Dr Szumita said, so that, for example, the preparation of an injection would be triggered at the appropriate time and the nurse would be able to see on screen when it would be ready. Prescription information could also be fed automatically into smart pumps, he added.
Barcoding enables more effective use of healthcare staff in the pharmacy and on the wards and provides a safety check, said Dr Szumita. When barcoding was introduced at Brigham and Women’s Hospital fewer than half of all medicines were barcoded and an in-house barcoding system had to be established. Now all unit doses are barcoded.
Other issues to consider are the format of the barcodes, the choice of scanners and the extent of any repackaging required. There are also drug dictionary issues to consider – for example, two generic versions of a drug would have different National Drug Code (NDC) numbers and therefore different barcodes.
“Scanability” can be a practical problem. Early versions of barcoded patient wristbands fell off and each patient had several spares, Dr Szumita explained. In the USA, the Food and Drug Administration requires that each product carries a linear barcode that contains the NDC number. Barcodes can be one- or two-dimensional (data matrices). Data matrices have the advantage of being easier to scan and still being readable when damaged. However, readers for these are more expensive – typically costing $300–$1,000 each.
Other practical issues had emerged. One type of fentanyl patch had three barcodes on its pack, making it difficult for staff to know which to read. Some packaging designs give the appearance of barcodes, and barcodes on small bottles are difficult to read. Two-dimensional barcode scanners tend to be very sensitive and sometimes read other codes that happen to be in the vicinity – such as those on cans of soup, Dr Szumita explained.
The total cost of implementing barcoding at Brigham and Women’s Hospital was $13–$15m. This prevented an estimated 13,500 medication errors annually. Dr Szumita noted that barcoding of medicines had significantly reduced dispensing errors. Turning to the impact on administration, Dr Szumita said eMAR error data for 23,000 patients and two million administrations showed that numerous “wrong-drug” errors had been intercepted, along with 810 “wrong-patient” errors and 2,089 “expired-medication” errors.
Barcoding has not eliminated all medication errors; one reason for this was staff developing “work-arounds” or shortcuts. Typical pharmacy “work-arounds” include not scanning all the individual dispensed items but scanning the same pack repeatedly, scanning a photocopy of a drug package barcode, and “skipping” the final scan and doing it after the goods have been issued. Nursing “work-arounds” include not scanning the patient or the drug at the bedside, giving medicines from a “stash” and then scanning the appropriate item after the administration process is complete.
In the discussion that followed, Dr Szumita conceded that radiofrequency identification (RFID) might supersede barcoding.
A number of lessons had emerged from the development of eMAR. The closed-loop system was judged to be helpful and effective but education and training costs had been significantly underestimated. “Superusers” among clinicians were needed to teach others, Dr Szumita argued. He added that 44 software changes had to be made to the CPOE system during development.
Another important aspect was involvement of doctors and nurses. Doctors had to be involved early and participate in decisions about screen design, implementation plans and staff training. Nurses had to be involved in decisions about equipment. As a result of this approach, at Brigham and Women’s Hospital, nurses now have “COWs” – computers on wheels – which they chose in preference to computer “tablets” that have to be carried.
Targeted medicines information
A new website for the National Electronic Library for Medicines (NeLM) is under construction and is due to be tested in May or June 2007. In a joint presentation, David Erskine (Acting Director, Regional MI Centre, Guy’s and St Thomas’ NHS Foundation Trust) and Sir Muir Gray (Director, National Knowledge Service, UK) described some of the planned features.
A series of “national knowledge weeks” will be launched and the top 50 health problems will be the subjects of the first series of these.
Another feature of the new NeLM website will be the option to link to information about medicines, such as guidance provided by the UK’s National Institute of Health and Clinical Excellence (NICE), summaries of product characteristics (SPCs) and patient information.
Mr Erskine suggested that the “book club” approach could be used to enable users to discuss a specific publication – such as a NICE guidance documents – online. He said this could be more powerful than simply providing the published information because it would capture the “softer” aspects, such as pharmacists’ opinions or experiences.
Sir Muir described how patient-centred care might work in the future. For example, a patient with hypercholesterolaemia could be sent an email reminder every six months to have his or her blood cholesterol measured. If the patient took no action this would be followed by reminders through his or her mobile phone.
A copy of the reminder would also go to the general practitioner. The results would go to the patient’s general practitioner and to his or her “healthspace” along with appropriate advice. If the patient failed to collect his or her repeat prescription, similar reminders would be triggered.
Teva Leadership Award
Andrew Alldred (Director of Pharmacy and Medicines Management, Harrogate and District NHS Foundation Trust) said more use of technician checking and the removal of the supply function from the pharmacist’s role on wards were two key recommendations made by the pharmacists in his team.
Mr Alldred received the Teva Leadership Award for a project designed to increase efficiency, modernise processes and improve patient access to medicines at his hospital. Harrogate and District NHS Foundation Trust operates a 400-bed hospital that has been rated as one of the NHS’s top-performing organisations. Expenditure on medicines, currently £4.7m annually, is growing at a rate of 12% per annum.
Three key elements of the service – inpatient dispensing, individual patient dispensing (IPD) and clinical pharmacy services – underwent modernisation. In the past, supply of medicines had been one of the duties of a clinical pharmacist, but now pharmacy technicians deal with this, leaving pharmacists free for clinical tasks such as drug history-taking and patient education.
Additional “checking” technicians and two medicines management technicians were appointed. By the end of the project the number of take-home medicines checked on the ward had increased from 20% to 65% and the average dispensing time for take-home medicines had decreased from 86 to 60 minutes. Savings of some £130,000 a year have been made through re-use of patients’ own medicines.
“Setting the direction and articulating the vision to stakeholders was the key to success and leading the changes through frontline staff also emerged as an important way to do things”, Mr Alldred commented. “These types of changes could be reproduced in many organisations.”
Pfizer Patient Safety Award
Victoria Magnal (Head of Aseptic Services, Royal Liverpool Children’s Hospital), winner of the Pfizer Patient Safety Award, described a project that investigated the feasibility of using end-product testing as a quality assurance measure for paediatric total parenteral nutrition (TPN) solutions. Critical path analysis was used to identify numerous possible errors in preparation of paediatric nutrition solutions. Accidental mix-ups of small-volume additives could result in large changes in final concentrations of critical ingredients such as glucose. The effects can be variable, as nutrient concentrations are increased progressively over the first few days of the feeding programme in neonates.
Ms Magnal explained that if glucose and water were accidentally switched, then on day 1, when intravenous feeding started, the patient would be at risk of hyperglycaemia, then at risk of hypoglycaemia later.
Various analytical methods were investigated, including measurement of refractive index and osmolality, and chemical analysis. However,
Ms Magnal concluded that so far no single method could detect all potential errors.
Aspects of patient safety in the NHS
In the UK, 59% of patients use the Internet to find information before attending a medical consultation – and this shows that the population is changing faster than the National Health Service, maintained Aidan Halligan (Chief Executive, Elision Health Ltd, UK). Considering aspects of patient safety in the NHS, he explained that sometimes the human element of care – such as simple acts of kindness or time spent with anxious patients – is overlooked. The imposition of targets has often been the cause of this.
The first step in reforming healthcare organisations is to understand the hidden values and who holds power in the organisation. The chief executive, the chief finance officer and the head of human resources form the most important group in a hospital. If a goal is perceived as irrelevant by this group then it will not be achieved, he said.
Dr Halligan concluded by drawing attention to a notice outside a glue factory which read: “Accident-free days: 415”. He posed the question: imagine the effect if hospitals could do this.