Closing the Loop

June 24, 2011
Erica Drazen In this three part series on medication administration, HCI looks at the information exchange points in the process where errors are
Erica Drazen
In this three part series on medication administration, HCI looks at the information exchange points in the process where errors are most likely to be made. In our first installment below, we examine the initial patient encounter to find out if CPOE is the key to reducing errors. In July, we'll look at the process from the pharmacist's point of view, as the order is received and filled. Finally, in August, our focus will turn to the final step in medication delivery — the bedside transmission of drugs from nurse to patient.

When the newborn twins of actor Dennis Quaid nearly died from an overdose of heparin it was big news — but hardly a rare occurrence. Though “the five rights” of medication administration are standard operating procedure these days, mistakes in medication administration are still frequent and the “closed loop” elusive. According to the most recent Chicago-based HIMSS Analytics survey, only 1.5 percent of United States hospitals have closed loop medication administration that incorporates medication ordering, pharmacy and bedside administration. Many feel that low number is linked with similar low adoption rates for CPOE. But with so few hospitals using CPOE, are they doomed to repeat tragedies like Quaid's?

According to Erica Drazen, a partner at Falls Church, Va.-based CSC Healthcare, to achieve an accurate initial physician order, “The first step is figuring out what you want to order, ordering it, and then getting that order accurately transmitted to the pharmacy.” She says that while most people think physicians' handwriting leads to errors in the initial order, it's the order itself that is more often the problem. “This is the part of the process where the biggest number of adverse events is created because the original order was flawed.” According to a recent Healthcare Informatics Webinar presentation by Ann Farrell, R.N., a principal at San Francisco's Farrell Associates, 39 percent of medication errors occur in the initial order. (See chart)

That means decision support for the physician is the order of the day. “Most of the major HIS vendors have that capability,” say Pam McNutt, CIO of Dallas-based Methodist Health System. “The real issue is how easy it is to use. And any way you look at it, somebody at your facility has to build all these alerts.”

Alerts and over alerting are big issues that allow the medication error rate to remain high for a simple reason: they can be turned off. According to Drazen, most of the drug interaction alerts come from a pharmacy database purchased from a commercial supplier — and they are all designed to over alert. “When those alerts come up, the pharmacist has to alert the doctor through traditional processes” she says. “That's a lot of phone calls. So they don't turn on all the alerting systems.”

Jamie Mooney, CIO at Norwalk Hospital in Norwalk, Conn., agrees that alerts are a big issue. “You don't want to be crying wolf,” she says. Mooney, who is using CPOE on a Kansas City, Mo.-based Cerner system, says constant feedback helps keep the alerts in check. At Norwalk, she says, alert modifications are made all the time directly to the Cerner system. “My staff goes in and makes the requested changes,” she says. “They're vetted through the CPOE committee chaired by our CMIO. And we have very strong change management around that.”

Pharmacists at Norwalk are also are present during ICU rounds with a computer on wheels. As the physician writes the order into Cerner, the pharmacist immediately verifies it. Though Norwalk's use of CPOE has dropped the medication error rate from 13.1 to 4.6 per thousand, Mooney says she believes process is important whether a hospital has CPOE or not. “Even if you don't have CPOE, you still have to have good basic processes,” she says. “It's the old IT rule of you don't fix a bad process by automating it.”

At Methodist, McNutt is not using CPOE, but has found a way to keep her error rate low by using an interface from Boxford, Maine-based Iatric Systems to capture the order into Meditech (Eden Prairie, Minn.) by scanning. “We have the unit clerk scan the order into Iatric,” says McNutt, adding that Iatric attaches it permanently to the Meditech patient record. “That way the pharmacist can bring up the actual paper. It's still a paper copy but you can zoom in and look at it with a little more clarity.” With the scanned version, alerts are still important. “You have to be careful not to over alert whether it's the pharmacist, nurse or physician,” McNutt says.

Alerts at Methodist go to the pharmacist directly from the Meditech system. “If the pharmacist takes action on an alert and needs to call the physician back, they will go in and post a comment saying ‘needing to speak to physician,’” she says. The nurse on floor who may be looking for that medication can see the status of all the medication orders by pulling up a screen to see where they are in the process. “I think we've done as good a job as one can do short of doing CPOE.”

Methodist also uses another system called clinical intervention software. “On top of the alerts we have built into Meditech, we have another system that will alert us to and track the clinical interventions these pharmacists make.” She says these are more subtle issues, such as requesting a more cost effective or clinically effective drug. Methodist is in the middle of switching out its current product for clinical intervention software and declined to give its name. “We hope to interface the new pharmacy intervention system directly into Meditech,” says McNutt. “Right now it's a standalone tool.”

But most agree that to do a good job, the pharmacy and the clinical systems must be the same. According to Mooney, mistakes may occur. “There's always going to be some translation that's going to happen through an interface and you are susceptible to errors,” she says. “If something changes in one system, you have to make sure it changes in the other one. It's really much simpler with an integrated system.”
“Source: Vendome Group Webinar, “Implementing Wireless Technology in Healthcare? Learn From Others' Experiences,” Farrell, Feb. 6, 2008.

Drazen says even if using CPOE, pharmacy databases will present a problem if the systems differ. “There is no standard set of alerts from one vendor to another,” she says, “so if your CPOE is using a different drug database than your pharmacy, you'll be getting different alerting. There's very little consistency between those pharmacy databases.” The integration between the pharmacy and EMR is so important that Drazen says it will essentially drive best-of-breed pharmacy out of business.

Finding workarounds is not easy. “It's a very challenging topic and there really aren't that many good solutions,” says McNutt. “The hard part is developing the right order sets and the right presentation to the physician.” She says it's important to remember that medications are only one aspect of the physicians' total view of the patient. They have radiology and lab (among others) to consider as well, and they typically have a low tolerance for navigating thorough lists of drugs and multiple screens.

“You have to develop order sets for them so they are able to easily order the things they want,” McNutt says. “From a technical standpoint, building that order set is not difficult. Getting the organization to agree on what needs to be in those order sets is the tough part, as is getting the physicians to use it.”

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