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The New Status Quo:
How eMM influences medication
incident reporting in a paediatric
hospital Natalie Tasker
Network Medication Safety Pharmacist
Learning Objectives
- Medication safety improvements expected with the
implementation of eMM
- Review actual medication incident reporting during the
rollout out of eMM and how this changes after rollout is
complete
- Describe how incident reporting influences changes to the
eMM build and improves patient safety.
Electronic Medicines Management Rollout
• Introduced in April 2016 –
staged roll-out design.
• Cerner – PowerChart®
• Two pilot wards chosen,
remaining randomised
• ED last to go-live
Objectives of the eMM Program
Improve patient safety and outcomes of care through:
• Reducing preventable adverse drug events
• Increase compliance with best practice medications protocols
• More cost effective expenditure on medicines
• Supporting better coordination of patient care across care settings
Improve efficiency of health services through:
• Reducing the average time taken to access key clinical information
• Reducing the numbers of bed days attributed to adverse drug events
• Better utilisation of clinical resources
Improve clinician satisfaction:
• Provide decision support and online electronic medication information that has been requested as
a priority by clinicians.
eMM Can Improve Patient Safety
• Improved legibility of prescriptions
• Forcing functions – no more incomplete prescriptions
• Decision support – dosing information available at the time of prescribing
• Interaction checking
• Allergy checking
• Reduced need for transcription from one paper medication chart to the next
• Reduction in the use of unapproved abbreviations
• Reduction in the need for telephone orders
• Easier to identify/contact prescriber
Incident Reporting System
The Incident Information Management System (IIMS) is a voluntary reporting
system used within our hospital to record clinical incidents.
IIMS was used to review incident data during the go-live period (11th April 2016 to
30th June 2016).
The same time period in 2015 was compared.
Reported Incidents
11th April to 30th June 2016 11th April to 30th June 2015
Number of medication/IV fluid related incidents
309 (22% increase)
240
Trended Data
10.0
15.0
20.0
25.0
30.0
35.0
40.0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
15 15 15 15 15 15 15 15 15 15 15 15 16 16 16 16 16 16Re
po
rte
d M
ed
ica
tio
n/IV
Flu
id I
nc
ide
nts
pe
r 1
00
0 a
dm
iss
ion
sReported Medication/IV Fluid Incidents per 1000 Admissions - CHW
(Six Sigma U-Chart)
Number of Reported Medication/IV Fluid Incidents per 1000 Admissions - CHW Average Reported Medication/IV Fluid Incidents per 1000 admissions - CHW
3UCL - CHW 2UCL - CHW
1UCL - CHW 3LCL - CHW
2LCL - CHW 1LCL - CHW
Between Red UCL and LCL (3 Standard of Error) - 99 % CIBetween Yellow UCL and LCL (2 Standard Error) - 95% CI
Between Green UCL and LCL (1 Standard Error) - 68% CI
eMM rollout commenced
at CHW
Increased Reporting During Rollout
• Increased vigilance of staff when implementing a new system
• Actual clinician concern regarding the system
• Documentation requirements from eMR unit
• Increased frequency of user error due to new system
eMM Incident Breakdown During Rollout
eMM Errors Non-eMM
Errors
Number of Errors 57 252
“Near Miss” 44% 7%
Prescribing Errors 72% 33%
New (Old) Error Types
• Documentation
• Incomplete prescription
• Wrong frequency/timing
• MAR (Medication Administration Record) not ceased at transfer
• Duplication
Incomplete Prescriptions – thing of the past?
Wrong frequency/timing
Daily vs 24 hourly
QID vs 6 hourly
First Dose Frequency
STAT vs routine
Almost 12 months later…..
January 2017
eMM Errors Non-eMM
Errors
Number of Errors 50 63
Administration Errors 26% 63%
Prescribing Errors 60% 27%
January 2017 Data
10
20
30
40
50
60
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb
15 15 15 15 15 15 15 15 15 15 15 15 16 16 16 16 16 16 16 16 16 16 16 16 17 17
Re
po
rte
d M
ed
ica
tio
n/IV
Flu
id In
cid
en
ts p
er 1
00
0 a
dm
issio
ns
Reported Medication/IV Fluid Incidents per 1000 Admissions - CHW(Six Sigma U-Chart)
Number of Reported Medication/IV Fluid Incidents per 1000 Admissions - CHW Average Reported Medication/IV Fluid Incidents per 1000 admissions - CHW
3UCL - CHW 2UCL - CHW
1UCL - CHW 3LCL - CHW
2LCL - CHW 1LCL - CHW
Between Red UCL and LCL (3 Standard of Error) - 99 % CIBetween Yellow UCL and LCL (2 Standard Error) - 95% CI
Between Green UCL and LCL (1 Standard Error) - 68% CI
eMM rollout started at
CHW
Oncology rollout
commenced
Incident Reports = System Changes
eMM Related Incidents – January 2017
Incident, as reported in IIMS Outcome/Comments –
Medication Safety Pharmacist & MEMORY team
Modified Release (MR) Preparations in eMM Several incidents have been reported throughout January where modified release opioids were confused with immediate release opioids. On paper, modified release preparations were prescribed by brand name for ease of recognition and to differentiate from the immediate release product. The paper NIMC also had a tick box to indicate that the product was controlled release.
The State-wide eHealth design decision was to name all products “MR” meaning modified release.
Due to the number of incidents, CHW has asked to review this decision and evaluate whether there are other tools within the system to alert staff that this is an order for a
modified release preparation.
Pharmacy and Pain team are also working together to develop education resources for the wards to highlight the
differences between immediate and sustained release opioids.
eMM Related Incidents – January 2017
Incident, as reported in IIMS Outcome/Comments –
Medication Safety Pharmacist & MEMORY team
Administration of Medications not documented in eMM A number of instances have been reported where the nursing staff have appropriately documented the administration of a medication, and then refreshed the screen, or viewed the MAR from a different computer and the administration is no longer documented. Duplication of doses or patient harm as not been documented, however, there is a high risk of this harm if this continues.
The eMR unit is aware of this issue.
If staff experience this issue they are asked to contact the eMR unit immediately on 50333 in order to be able to investigate the cause of the
issue.
eMM Related Incidents – January 2017
Incident, as reported in IIMS Outcome/Comments –
Medication Safety Pharmacist & MEMORY team
Use of Unapproved abbreviations
Pharmacy and eMR Unit have noted prescribers use of unapproved
abbreviations in the electronic environment, in particular the use of the
letter T. The letter T has been noted to be used to indicate one tablet, or
one drop, instances of TT reported to mean two drops have also been
reported.
The letter T was not an approved abbreviation in prescribing on paper, nor
is it an approved abbreviation in the electronic environment.
There is no approved definition for what “T” means, and as such, nursing
and pharmacy staff are left to interpret the order and guess what the
prescriber has intended. This is unsafe.
Prescribers are reminded to ensure that their orders are
clear and require no interpretation.
The appropriate was to designate “ONE” in the electronic
environment is the use of the number “1”.
Nursing and pharmacy staff will ask prescribers to modify
orders that contain ambiguous and unapproved
abbreviations.
The January 2017 Medical Staff Update alerted staff to this
issue.
eMM Related Incidents – January 2017
Incident, as reported in IIMS Outcome/Comments –
Medication Safety Pharmacist & MEMORY team
Indication is Mandatory
Pharmacy and the eMR Unit have also noted prescribers completing the
indication field with a full-stop “.” or an “X” or even just a space.
The indication is a mandatory field in eMM, and this is an important safety
activity.
Similarly, there have been reports of prescribers documenting inaccurate
indications for some medications.
The indication (the reason why the patient is prescribed the
medication) is critical clinical information for other
healthcare professionals involved in medicines
management.
It allows the order to be reviewed in the context of why the
medication was prescribed, reducing the risk of
misinterpretation of the order.
This is especially important for medicines which have
different doses for different indications.
Prescribers are reminded not to “work” the system by using
a full-stop and ensure clinical documentation is complete
by entering the clinically appropriate indication.
Ad Hoc Improvements
Addition of high alert to hydromorphone
Add order sentence for Creon 10000 (nursing staff observed to be administering more
frequently than prescribed).
Use of “.” and “(spacebar)” for indication prompted review of popular order sentences
such as omeprazole in oncology.
Addition of order sentence for heparinised saline locks for PICC lines
AND THE LIST GOES ON AND ON…..
Where to From Here?
• Continue to monitor the error rates
• Use data to drive system change
• Gather feedback from clinicians regarding usability and utilise
this to make system changes
