Peer Reviewed Article on Minimizing Medication Errors Through Technology in Hospitals
BMJ. 2000 Mar 18; 320(7237): 788–791.
Using it to reduce rates of medication errors in hospitals
Data continue to testify that medication errors are frequent and that agin drug events, or injuries due to drugs, occur more frequently than necessary.ane – 4 In fact, the frequency and consequences of iatrogenic injuries seems to dwarf the frequency of other types of injuries that take received more public attention, such as aeroplane and auto crashes.2 A recent meta-analysis reported an overall incidence of vi.7% for serious adverse drug reactions (a term that excludes events associated with errors) in hospitals.iv Between 28% and 56% of adverse drug events are preventable.3 ,5 – 7
Though the reasons this outcome has received so little attention are complex, the reasons that medical injuries occur with some frequency are maybe less so; medicine is more or less a cottage manufacture, with piddling standardisation and relatively few safeguards in comparison to, say, manufacturing. In fact, most of the systems in place in medicine were never formally designed, and this holds for the entire procedure of giving drugs.
Take, for instance, the allergy detection process used in our infirmary several years ago, which was similar to that used in nearly hospitals at the time. Physicians, medical students, and nurses all asked patients what their allergies were. This data was recorded at several sites in the medical tape, though at that place was no one central location. The information was also required to be written at the top of every order sheet, although in practice this was rarely done. The pharmacy recorded the information in its computerised database, but it found out virtually allergies just if the data was entered into the orders, and frequently it was not. Checking by physicians and pharmacy and nursing staff was all manual. This data was non retained between the inpatient and outpatient settings, or from admission to admission. Non surprisingly, most ane in iii orders for drugs to which a patient had a known allergy slipped through.3 This system has been replaced past a arrangement in which all allergies are noted in one place in the information system, drugs are mapped to "drug families" (for case, penicillin) so that checking of drugs within classes can exist done, information is retained over time, and checking is performed by the information organisation, which does not fatigue.
Using information technologies to prevent medication errors
Several interventions involving information systems accept been shown to reduce medication errors considerably, and many others have hope but have not been sufficiently studied. Among these are computerised physician order entry, computerised md decision support (which is often, though not necessarily, linked with order entry), robots for filling prescriptions, bar coding, automated dispensing devices, and computerisation of the medication administration tape (fig 1).
Role of automation by stage in the medication process. Automation of some functions may affect more than than one stage
It is essential to country at the offset, however, that information technologies are non a panacea, and that they may make some things meliorate and others worseeight; the net result is thus not entirely predictable, and it is vital to study the impact of these technologies. They have their greatest impact in organising and making available data, in identifying links between pieces of information, and in doing boring repetitive tasks, including checks for problems. The best medication processes volition thus not replace people but will harness the strengths of information technology and permit people to do the things best washed by people, such equally making circuitous decisions and communicating with each other.
Computerised physician lodge entry
Computerised physician order entry (CPOE) is an application in which physicians write orders online. This system has probably had the largest impact of any automated intervention in reducing medication errors; the charge per unit of serious errors roughshod 55% in 1 study9 and the rate of all errors brutal 83% in another.x Computerisation of ordering improves safety in several ways: firstly, all orders are structured, so that they must include a dose, route, and frequency; secondly, they are legible and the orderer tin be identified in all instances; thirdly, data can be provided to the orderer during the process; and fourthly, all orders can be checked for a number of problems including allergies, drug interactions, overly high doses, drug-laboratory bug (giving a patient a drug when they have a known biochemical factor that predisposes them to risk), and whether the dose is appropriate for the patient's liver and kidney function (fig two). A big decrease in the number of errors can be accomplished by computerising the process even without providing much decision support; in one written report even a elementary system reduced medication errors past 64%.10
Computerised checking of a chemotherapy dose. The computer calculates the body surface surface area, displays the calculation, and asks if information technology is correct. The dose is so checked against a tabular array of doses, with daily and weekly limits. If a dose limit is exceeded the society is suspended until it tin can be reviewed and approved
Computerised decision support is also valuable for reducing the frequency of adverse drug events, even when not linked to computerisation of the ordering process. In an elegant series of studies, the group from LDS Hospital in Salt Lake City, Utah, showed large reductions in adverse drug events due to antibiotics.xi Also, a community hospital in Phoenix, Arizona, used a computerised alarm arrangement to target 37 drug-specific adverse reactions—for example, arrhythmia caused by digoxin—for which they looked for patients receiving digoxin who had hypokalaemia.12 They detected opportunities to prevent injury at a rate of 64 per grand admissions; 44% of the truthful positive alerts had not been recognised by the physician.12 This approach works partly by helping clinicians to associate key pieces of data, which can exist problematic given the overwhelming stream of data confronting them.
Though computerisation of ordering dramatically decreases the overall charge per unit of medication errors, computerised decision back up may be specially important for preventing errors that actually result in injury. In 1 study, computerised order entry with relatively express determination back up resulted in a larger subtract in near misses (84%) than in errors that actually resulted in injury (17%)9—but in a afterwards evaluation, afterward more decision back up had been added, the rate of errors resulting in injury brutal from 2.9 to 1.1 per g patient days.x
Robots for filling prescriptions
Automation may likewise reduce error rates in filling prescriptions. Robots have been used for this in some big hospitals for some time, and more recently in smaller hospitals, and they are increasingly existence used in the outpatient setting. No published data are available, but in i unpublished study a robot decreased the dispensing error charge per unit from 2.9% to 0.6% (PE Weaver and VJ Perini, American Club of Health Organization Pharmacists, 1998).
Bar coding
Although few data from wellness care are available, bar coding of drugs also seems useful for reducing error rates.13 The major barrier to implementation has been that drug manufacturers accept not been able to agree on a mutual approach; this should exist legislated. Bar coding is widely used in many industries outside medicine; information technology results in mistake rates about a sixth of those due to keyboard entry and is less stressful to workers. Some hospitals in the United States have already successfully implemented bar coding—for instance, at Concur Hospital in New Hampshire bar coding was associated with an 80% fall in medication administration errors (D DePiero, personal communication). Bar coding tin can rapidly ensure that the drug at mitt is actually the intended one and can also be used to record who is giving and receiving it, equally well equally various time intervals.
Automated dispensing devices
Automated dispensing devices tin be used to hold drugs at a location and dispense them just to a specific patient.xiv Such devices, specially if linked with bar coding and interfaced with hospital information systems, can decrease medication error rates substantially. Without these links the result of these devices is unclear14 – sixteen; in one study such a system was actually associated with an increase in medication errors.17
Automatic medication assistants tape
Another key function of the medication use process is the medication administration record, on which the clinicians who really administer drugs record what has been given. Computerisation of this function of the process, peculiarly if linked to computerised social club entry, could reduce errors and allow detection of other types of errors relating to the quantities of drugs that are to be taken "as needed."
Computerised adverse drug issue detection
To monitor how any process is performing, it is essential to be able to measure out its outcomes. Traditional monitoring relies on self reporting, which radically underestimates agin drug events, detecting only about 1 in 20.xviii Even so, computerised information can exist used to detect signals (such as use of an antidote or a high concentration of a drug) that are associated with an adverse reaction.19 ,20 A pharmacist tin can and so evaluate the incident and make up one's mind whether information technology represents an agin drug event, and these data can and so be used for root crusade analyses. In a caput to caput comparison with chart review and spontaneous reporting, a computerised monitor was found to detect 45% of events detected past whatsoever method, compared with 64% for chart review and simply four% for voluntary reporting.20 The cost of the computerised monitoring was only 20% of that for chart review. This is the showtime practical mode to monitor the medication process on an ongoing basis.
Diffusion of these technologies
The tools that are now available should eventually be used in all hospitals; the overall approach should be analogous to that used in infection control, in which data about complications are used to continuously ameliorate the system. Given the potential touch of these technologies, their diffusion has been surprisingly boring. One reason may be the lack of research showing how much of a difference the technologies make. Funding for such research has been relatively limited, and relatively little support has come from the developers of the technologies. Another, more of import reason is lack of demand from the healthcare industry. Safety has not been a loftier priority in medicine, in part considering the trouble of safety is generally undervalued. Ane reason for this lack of appreciation is that medical accidents occur in ones and twos rather than in large groups; moreover, many of those involved are sick and elderly. Fortunately, public concern virtually the issue is substantial, and increasing, and the healthcare industry is showtime to take a more than active interest.21
The medication arrangement of the future
In futurity, physicians will write orders online and get feedback nearly issues like allergies and decision support to help them choose the all-time treatment. The orders will exist sent electronically to the pharmacy, where about volition be filled by robots; complex orders will be filled past pharmacists. Pharmacists volition be much more clinically oriented and will focus on promoting optimal prescribing and identifying and solving problems. Automated dispensing devices will be used by nurses to provide drugs to patients. All drugs, patients, and staff volition be bar coded, making it possible to determine what drigs have been given to whom, past whom, and when.
Conclusions
Several information technologies have been shown to improve the safety of drugs. Computerised physician order entry seems to be the most potent of these, and it can be expected to become even more useful as more data become computerised. The technology can be expected to diffuse rapidly equally all major vendors are developing such systems and many are pursuing internet based applications which would allow ordering and provide a common platform. Information engineering science should also improve rubber in other parts of the process, including dispensing and administering, but the full benefits volition non exist achieved until all the components are electronically linked.
The net result of the in a higher place volition be a much safer system, which volition still crave substantial human being guidance. Moreover, the people using the organization will have fewer menial tasks and a more than rewarding function: physicians will hash out drug choices with patients and other providers rather than worrying about missing an allergy; pharmacists volition deal with circuitous drug orders, counsel physicians nigh choices, and investigate issues that occur, rather than simply filling prescriptions; and nurses volition talk with patients and monitor for agin reactions, rather than just passing pills.
Acknowledgments
I thank Joshua Borus for help with preparation of the manuscript.
Footnotes
Competing interests: DB has received honoraria for speaking from the Eclipsys Corporation, which has licensed the rights to the Brigham and Women's Hospital Clinical Data System for possible commercial development, and from Automated Healthcare, which makes robots that dispense drugs. He is also a consultant and serves on the advisory board for McKesson MedManagement, a company that helps hospitals to preclude adverse drug events, and is on the clinical advisory board for Becton Dickinson.
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