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Learning’s from an Ad Hoc Evaluation of the
Taranaki DHB (TDHB)ELECTRONIC PRESCRIBING PILOT
1/3 National Pilot Sites
TDHB INTEGRATION focus MedChart v6.3 with
limited decision support 1 way interface ePharmacy
+ ePharmacy 1 way interface with Pyxis
+ Pyxis + eMedRec
Background
Electronic Prescribing
“not just a technology –it is a complex design / redesign of clinical processes that integrates technology to optimise physician
ordering of medications. By its nature it reconfigures hospital operations and
workflow and affects virtually all operations”
What we knew…
End User perspective 24/7 multi-user access from anywhere 100% clear, complete prescriptions Decision support Allergies, Duplication, Interactions, Dose
Ranges, Rules
Medication Information Interaction checker, Datasheets, TDHB protocols
Integration of tasks Administration, Pharmacist Review
Integration of systems Allergies, Dispensary, Laboratory
What we knew…
IF DONE WELL …improves outcomes MedChart v5.1 (St Vincent’s, Sydney)
Reduces error rates by 60% Compared to 5-10% for National Drug Chart Type
procedural errors clinical errors serious errors
Remaining 40% errors 15% errors introduced by the system ” eg Wrong strength / Timing
= FOCUS OF THIS PRESENTATION .
What we knew…
IF DONE WELL…improves outcomes Workflow
No changes in time spent in direct care on medication related tasks
Prescribers spent time with doctors & patients Nurses spent time with doctors
What we knew…
BUT its NOT a magic bullet Can contribute to errors Unintended consequences expected 1
Increases mortality if poorly implemented 2
Environment matters more than the system 3
1. Campbell E et al. Types of unintended consequences related to CPOE. JAMIA 2006; 13(5):547-556.2. Han YY et al. Unexpected increased mortality after implementation of a commercially sold computerised physician
order entry system. Paediatrics 2005; 116(6):1506-123. Metzger J et al. Mixed results in the safety performance of computerised physician order entry. Health Affairs 2010; 4:
655-663
What we knew…
Also will … NOT … fit everything on one page NOT … stop scripts being “CLEARLY” wrong NOT … stop you doing something stupid NOT … make clinical decisions for you NOT … replace communication with staff
What we knew…
Complex CONTEXT is everything
HOW is as important as WHAT
What we knew…
What we knew…
…the VALUE PROPOSITION…
...Will need to learn to do things differently,
but there will be benefits in return…
In the TDHB context Implement safely? What were the unintended consequences? What were the new types of errors ? How could we mitigate the risks associated with these?
What we wanted to know…
Use existing data where-ever possible Extensive baseline Monitored at 4, 8 & 12 months
Quality improvement approach
Started with subset of Pilot ward to understand TDHB context & validate / refine workarounds < 4 months 17 patients 3 prescribers ≥ 4 months 25 patients 48 prescribers
Pro-actively engage end-users & promote feedback
Approach
Approach
Prescribing Audit Medication Safety Database Errors Grade 1-5
Pharmacist Interventions Errors Grade 1-3
Pharmacist Contributions Pharmacist Ward Education Log Ward Event Log
Monitoring
Each Audit Subset of results Strategies used
Training / Education Configuration Workflow Enhancement requests
Lessons learned
Outline
Compliance with TDHB Prescribing Guidelines 59 parameters
Completeness Legibility Legality
24hr snapshot n=2413 prescriptions
All prescriptions vs Pilot ward 2012 Pilot ward paper vs electronic 2012
electronic scripts 8.4% All & 32% Ward
Prescribing Audit
Legibility to 100%
Legality to 100% - except for dose
Completeness - Patient flagging of supplementary
charts allergy documentation
re-chart dates numbering of multiple charts
Prescribing Audit
Completeness – Drug ceasing modifications minimum dose intervals for PRNs
compliance with generic prescribing
use of review/stop dates dose range guidance use of indication
Prescribing Audit
Actions Enhancement requests Vendor / NeMP
Dose forms that require dose creams & ointments
Unapproved abbreviations mcg & IU
Review date function medicine not drop off chart
Lessons Learned Small changes for 100% legality (& legibility) Completeness improved in most instances
Prescribing Audit
2 years pre & 1 year post n=1119
Pilot ward 6.6% All errors (n=78)
2 year pre 65% (n= 48)
1 year post 35% (n= 26)
Sub-analysis 4, 8 & 12 months Place in Medication Use process Type of error Factors involved
Medication Safety Database Grade 1-5
88% events involved MedChart after 4 mths when pilot expanded end user reporting by 12mths
Place in Medication Use process Prescribing 39% (Transcribing 56%) Administration 57% Pharmacy 4%
Medication Safety Database
05
10152025 Reported Errors
4mth 8mth 12mthPeriod
Medication Safety Database (Grade 1-5)
Types of Error Extra dose 60%
Withholding 64% Wrong start date 29%
Wrong strength 8.7% Wrong time 8.7% Omission 8.7% Wrong patient4.2% Duplication 4.2% Missed dose 4.2%
Medication Safety Database
Medication Safety Database (Grade 1-5)
Factors Involved Not check Admin History 35% System defaults 30% Alert issues 30% Dual processes 30% Integration 4%
Medication Safety Database
Withholding New workflow
= not medication specific + 2 steps required + poor visibility
3 different workarounds trialled…1. Medicine charted + Administration
Alert2. Medicine ceased + Prescribing Alert3. Medicine Blocked + Prescribing Alert
Medication Safety Database
Withholding1. Medicine charted + Administration Alert
Alert after patient selection, NOT at Administration Added in QUALIFIER (displayed at point of Admin) Added in Prescribing ALERT
… worked well with 3 prescribers but with 48 infrequent prescribers …
Medication Safety Database
Withholding2. Medicine ceased + Prescribing Alert
… no reported issues but risk of medicines not being restarted …
3. Medicine blocked + Prescribing Alert Remains charted but unable to be administered Flagged on “Overdue Meds” screen (Nurse)
…Not automatically flagged on “Patient Summary” screen (Dr rounds)…
Medication Safety Database
Withholding Actions
Training scenarios
Education Campaign
Enhancement Vendor / NeMP
Preventing roll out to surgery
Medication Safety Database
Wrong start date/time Transcribing
New workflow = Defaults to start medicine at NEXT available dosing time
Medication Safety Database
Wrong start date/time Action
Training Dr scenarios Educate
Nurses about doctor workflow, especially defaults Pharmacists focus on timing issues for new
admissions
Medication Safety Database
Nurse education about prescriber defaults
Medication Safety Database
Strength / Dose mismatch New workflow = Prescription includes strength
Medication Safety Database
Strength / Dose mismatch Action
Training scenarios Education
Doctors about strength /dose display in Admin screens
Campaign for recommended workflows
Medication Safety Database
Strength / Dose mismatch Action
Nurse Workflow Education Select medicines from Pyxis in “Administration” screen CHECK medicines in “Confirmation” screen (reads like
a sentence)
Medication Safety Database
Strength / Dose mismatch Action
Doctor Workflow Education If dose expected to change a lot chart without strength
For other dose changes, where-ever possible “cease” medicine and start new strength (rather than editing old strength)
Medication Safety Database
Strength / Dose mismatch Action
Enhancement Vendor / NeMP
Delivered 8.1.1 Prompt Doctor on editing dose to select more appropriate
strength if exists Removed strength from left hand side of Nurse “Administration”
screen
Medication Safety Database
Not checking Administration History New workflow =
Separate screen & extra mouse clicks Not visible at time of Administration
Action Simplification of 7 steps into 3
1 PATIENT CHECKS = Allergies, Alerts, Admin History (in DRUG ROOM) +
2 PARKING = Selection, Retrieval, Checking (in DRUG ROOM) +
3 ADMINISTRATION = 7 Rights (at BEDSIDE)
3 A’S Education Campaign
Medication Safety Database
Not checking Administration History Action
Enhancement Last dose administered viewable in Administration screens Delivered v8.1.1
Medication Safety Database
Lessons learned Compliance poor
with workarounds when > 1 step when > 1 extra mouse click
Professions need to understand each others workflow
Users need to be familiar with new types of errors
There is always another way … you just need to find it
Medication Safety Database
Pharmacist Interventions (Epiphany) Grade 1-3
Pre 2 years vs Post 1 year
All n = 14959
Pilot Ward n = 941 (6.3%)
MedChart Involved n = 81 (21.5%)
Sub-analysis Place in Medication Use process Phase in Patients Admission Event Severity Type of Event Medicines involved
Pharmacist ‘Error’ Interventions
Event Severity
Place in the Medication Use Process Transcribing
Type Illegal/Illegible/Incomplete Wrong Drug Regimen Wrong Dose Regimen Duplicate Therapy
Pharmacist ‘Error’ Interventions
Wrong Drug New workflow = Selection of medicines from list of forms & strengths
Pharmacist ‘Error’ Interventions
Wrong Drug Action
Training Screen shots of common mistakes Importance of checking full screen
Pharmacist ‘Error’ Interventions
Duplicate therapy despite DUPLICATION decision support Alert Fatigue
Due to current medicine definition “within past 24hrs” ie any Edit to a medicine resulted in an Alert
Action Change definition of current medicine to “0 hours” Manage risk of “stats” duplication Given = Ceased = No warning
Change Patient Summary screen to default to past week Train Drs to check Patient Summary screen for recently ceased “Stats”
Pharmacist ‘Error’ Interventions
Medicine Events for high risk or error prone drugs
warfarin morphine oxycodone diltiazem insulins metoprolol
Pharmacist ‘Error’ Interventions
Lessons learned Prescribers need support in new prescribing
requirements
Infrequent users forget workarounds
High risk drugs are complicated to prescribe Need to audit & develop new strategies / workflows
Alert fatigue Minimise Alerts where ever possible
Need new categorisation of errors for ePrescribing More efficient recording & data analysis
Pharmacist ‘Error’ Interventions
Process issues Transfer Paper and electronic chart used concurrently in error Integration +++
WebPAS Non-MedChart wards - “Meds Current at Transfer” not easily
identified Appointments - Pharmacist annotations fall off
Pharmacist Prescriber Advice Post Go-Live only
Transfer Actions
Training “Spot the 7 errors”
Pharmacist Prescriber Advice Post Go-Live only
Sample Chart
Actions Training
Pharmacists trained in areas problematic for Doctors/Nurses
Enhancements +++ Ability to print chart as at transfer Ability to electronically re-chart once transferred back Pharmacist annotations at transfer ADT messages not recognised by MedChart
Pharmacist Prescriber Advice Post Go-Live only
Lessons learned Easier to train small, stable group in workarounds
Pharmacists backstop for Multi-step processes Withholding, Alerts, Qualifiers, Duration
Integration a work in progress
Multiple issues at transfer
Dual systems increase risk of errors
Pharmacist Prescriber Advice Post Go-Live only
Complex CONTEXT is everything
HOW is as important as WHAT
What we found out…
What we found out…
…the VALUE PROPOSITION…
...Will need to learn to do things differently,
but there will be benefit in return…
Monitoring essential ….You don’t know what you don’t know… Environment & product continually changes
Key Lessons
Small & Often
User Engagement needs to be ongoing & intensive
Engagement wanes High user turnover Infrequent users struggle with workarounds Regular users don’t see the need for training
updates
Go to the UserDedicated resource
Key Lessons
Training Constantly review Educate professions about each others workflows Educate about new types of errors HOW IS MORE IMPORTANT than what
Success is dependant on the End User
& their feedback
Key Lessons
Workflow Changes To be expected, but.. Will be modified by staff & lead to unintended
consequences Some workarounds are safer than others Need to be identified Constant challenge
…..Managed most issues safely
Key Lessons
Key Challenges Maintaining End User Engagement Withholding Dual systems / Transfer
Pilot period important to understand context-related unintended consequences but
then…
ROLL OUT
Key Lessons
Configuration Vendor
Talk different language so define problems / solutions clearly Clarify, re-clarify & re-visit
Other DHBs valuable resource Liase regularly & re-visit Site visits invaluable
Always another way – you just need to find it!
Key Lessons
Enhancements Sites / Wards have different needs
Flexible Configurable options Site collaboration
Process needs to be supported Nationally
End User involvement earlier in the process
Key Lessons
End User is the
Final Message
Contact
Table 1 MedChart Associated Events & Issues Identified at TDHBType Description Medication
Incorrect Start Date/Time
Regularly” scripts default to todays date, but not due till later
in the month Start time defaults to next available due dose & was not edited
Incorrect Timing
Medicines (such as Madopar) prescribed twice daily at 8am/8pm when should be tailored
Frequencies have pre-specified default times which may not be appropriate for certain medicines, however a Dr would not previously had to specify exact time . eg three times daily (= 8am, Noon, 1800) for medicines that need to be taken on an empty stomach
Medicines prescribed at mealtimes that should be on an empty stomach
Medicines prescribed (via protocols) apart from meals that should be with meals
Eye drops charted hourly and need qualifier to say “during waking hours”
Incorrect Frequency Frequency defaults to ‘once daily’ and was not edited
Frequency & Administration times
out of sync
Admin times can be edited by nursing /pharmacy staff, but this may not match the prescribed frequency (which can only be changed by prescriber) eg “in the morning at 1800”
Duration issues
Once duration complete, script ceases and in error may not be continued (or have dose review) when should be
Prescribers do not want script to “fall off” so put no duration =
overtreatment and potential resistance Editing script, duration defaults to original duration and get overtreatment
and potential resistance
Prednisone
Table 1 MedChart Associated Events & Issues Identified at TDHBType Description Medication
Incorrect Medicine drug database categorisation of medicine contributed to confusion Hep saline
Incorrect Strength of medicine
Dr would previously have had to chart dose only (not strength), but now has to chose down to strength, and when editing dose downwards, the strength should have been changed also
incorrect medicine strength & for what on stock (dose charted in mL)
EnoxaparinMethotrexateMorphine
Incorrect Form or
Formulation
Dr would not have had the choice between the 2 different preparations and choose the wrong one
eg MDI vs DPI, Capsules vs Dispersible Tablets, Immediate Release vs Slow Release, Otrivine Menthol Nasal Spray vs Otrivine Nasal Spray
Brand issues
Cannot chart by brand unless you know the brand nameeg insulin should be charted by brand, but if search by insulin, you do not get the Penmix brand option (as it does not contain insulin in its description)
Pharmacist annotations (eg for brand) drop off when patient goes for a clinic
appointment
Route issues
Change to a PEG tube requires re-charting of all medicines
Vancomycin infusion given orally for C. Diff
Duration issues
Once duration complete, script ceases and in error may not be continued (or have dose review) when should be
Prescribers do not want script to “fall off” so put no duration = overtreatment and
potential resistance Editing script, duration defaults to original duration and get overtreatment
Prednisone
Table 1 MedChart Associated Events & Issues Identified at TDHBType Description Medication
Duplication of Medicines
Due to alert fatigue Due to duplicate warnings not firing for locally added pack Due to different script types for the same medicine displaying on different
tabs (regular vs prn vs stat vs variable dose) Due to lack of familiarity with how to use variable dose functionality to edit a
dose
Withheld medicines
Withheld medicine given when no place in the process was set for alert to fire (ie passive alert only)
Withheld medicine was given when “at administration” alert was overridden Withheld medicine given when “at administration” alert date was set
incorrectly (ie had expired the previous evening)
Minimum Dose Interval with PRN medicines
If a dose is given late on the first day (where minimum dose interval is set to 1 day), the subsequent doses must be given late every day as not available until late
Issues with the process of using the electronic
chart
Medicines omitted on transfer from paper chart to MedChart
Paper chart & electronic chart being used concurrently Resupply, Source information and Administration comments fall off the electronic
chart when a patient goes for an appointment
ADMISSION TO HOSPITAL
DISCHARGE FROM HOSPITAL
Key Messages Key Messages
Medicine and allergy information from:
• Patient (+ family, caregivers)
• GP/specialist
• Community pharmacy
• Rest homes
• Other hospitals
• Ambulance
Allergy Warning + ADR
▪ Input by pharmacists
▪ 3+ sources used
▪ Discrepancies listed as
unintentional / intentional
Medicine and allergy information to:
Dx summary (inc DMCS)
Dx scripts
DMCS
Yellowcards
Patient info leaflets
Patient
Community pharmacy
Rest homes
Other hospitals
Discrepancies must be resolved by a doctor within 24 hours of arriving in ED
Patients own medicines into “green bag”DMCS = discharge medicines changes summary
e-MEDICATION RECONCILIATION
e-Prescribing
e-Administration
e-Dispensing
Pyxis(Automated Drug Distribution
System)
Pyxis “batching” Retrieve ≥ 1 patient at a time DRUG ROOM Administer 1 patient at a time BEDSIDE
…but only 1 Administration step in MedChart
How did other sites manage time delay between Retrieval & Administration? National workshop
Process mapping Retrieval annotated on paper chart in drug room as a separate ste
= 2 Step Administration PARKING
TDHB
Regular scripts defaulting to todays date New workflow = Dr to specify start date/time rather than
just frequency
Actions Education of Nurse in Doctor workflow & new types of errors Training scenarios Enhancement (blank default)
Delivered 8.1.1
Pharmacist ‘Contribution’ Interventions
Medication Safety Database (Grade 1-5)
Place in Process sub-analysis by Type Prescribing
Extra dose (withholding) 25% Duplication 25% Wrong Drug (strength /dose mismatch)25% Omission 25%
Transcribing Extra dose (wrong start date) 75% Omission 25%
Medication Safety Database
Medication Safety Database (Grade 1-5)
Place in Process sub-analysis by Type Administration
Extra dose withholding 44% wrong start date 22% other 6%
Wrong dose (strength) 11% Wrong time 11% Missed dose 6%
Medication Safety Database
Warfarin new workflow Medicines arranged in “tabs” by script type Editing dose workflow different from other
medicines Had to select brand (incorrect default)
Pharmacist ‘Error’ Interventions
Action Warfarin
Rules to alert infrequent prescribers to unusual workflow
Removal of “ALL” tab Enhancement
Change default configuration to brand “unspecified”
Pharmacist ‘Error’ Interventions
Pharmacist Contributions (Epiphany) Grade 1-3
Pre 2 years vs Post 1 year
All n = 6061
Pilot Ward n = 919 (15.2%)
MedChart Involved n = 26 (9.8%)
Pharmacist ‘Contribution’ Interventions
Administration & Formulation Advice Frequency & Administration times out of sync
Default frequency morning = 8am Frequencies have pre-specified default times Editing of Administration times by nursing staff
Regularly scripts default to todays date
Formulations Dispersible vs normal, DPI vs MDI
Pharmacist ‘Contribution’ Interventions
Administration & Formulation Advice Frequency & Administration times out of sync
New workflow = Dr to specify administration times ; frequency defaults
Actions Rules to warn when Administration times need to differ from defaults
Change configuration “mane 08:00” to “od 08:00”
Training scenarios Education re: limitations for Nurse being able to “edit administration
times”
Pharmacist ‘Contribution’ Interventions
Lessons learned Nurses need to understand Drs new workflow (eg
defaults) & potential for new types of errors
Change in work responsibilities created tensions Dr now needs to think about nursing workflow (Admin
times) Education of Drs about nursing workflow
Pharmacist ‘Contribution’ Interventions
Incorrect strength for ward stock Morphine oral 2mg/ml prescribed as first choice on list Dose displays as mL on Administration screens BUT only 10mg/mL held on ward stock (2mg/mL Paeds only) & on Quicklist
Action Change 2mg/mL to NON-FORMULARY to guide prescriber to select 10mg/mL
Pharmacist Prescriber Advice Post Go-Live only
Medication Issues Incorrect strength for edited dose Incorrect strength for ward stock Dose edited but not qualifier Route issues High frequency medicines Minimum dose interval for PRN medicines
If dose given late on first day, subsequent days doses can’t be started till late
Pharmacist Prescriber Advice Post Go-Live only
Medication Errors