e Prescribing: Essential safety tool or IT

gimmick Gareth Collier

NWIS/WHEPPMA

WHEPPMA Welsh hospitals electronic prescribing and pharmacy medicines administration

Acknowledgements Mrs Cheryl Way, Dai Rose, Phil Ransome,

Rebekah Williams

100 years of Medicine

100 Years of Medicine

Introduction

The utilisation of electronic systems to facilitate and enhance the communication of a prescription,

aiding the choice, administration and supply of a medicine through information and decision support

whilst providing a robust audit trail for the entire medicines use process

Definition e Prescribing/CPOE

Definition A hospital patient discusses her medication with the healthcare team

on their ward round. The pharmacist team-member explains proposed changes to the

medication, which the patient will administer herself. The pharmacist also discusses learning

points with other team members.

New medication is agreed between members of the clinical team and ordered at the bedside

though a radio computer link to an automated dispensary, where robotic systems pick the new

medicines and dispatch them to the patient’s ward via a pneumatic tube.

Computer technology updates the electronic patient record, to which the patient’s GP has

access. The medication that has been issued is simultaneously recorded to update stock

records and order fresh supplies

Reports • A Spoonful of Sugar The Audit Commission 2001

• 10.8 % of medical patients experience an adverse event, 46% preventable

• 33%lead to greater morbidity or death

• Each event mean 8.5 additional days in hospital

• £1.1 billion in additional cost/yr

• 12% adverse events related medicines

Reports

• The Andrews Report 2014: Trusted to Care.

• Welsh Audit Office report 2016: Managing medicines in primary and secondary care • Electronic prescribing could significantly improve the safety

and efficiency of medicines information in hospital but progress has been slow.

• Carter Report 2016: Operational productivity and performance in English NHS acute hospitals: Unwarranted variations.

Types of Medication Errors Q J Med 2009;102:513-521

• Prescribing faults

• Irrational, inappropriate, ineffective(6-57%), under and over prescribing

• Prescribing errors writing the prescription(50%)

• Manufacturing

• Administration

• wrong dose, route, frequency, duration

• Monitoring

• Knowledge based, Rule based, Action based, Memory based

• Catastrophic, major, moderate, minor, insignificant(UK, NPSA risk matrix)

Size of the problem • Cousins et al BJCP 74:4;597-604 2011

• Medication incidents reported to NRLS(national reporting and learning system)

• 8%-11% from 2005 to 2010

• Acute sector 75% vs 8.5% primary care

• 16%( 86821) in 2011 results in actual harm

• 0.9%( 822) in 2011 death or severe harm

• 1-10% of all prescribing, dispensing and medicine administration procedures in the UK include errors

• 49% of IV medicines

• One-fifth of clinical negligence litigation claims(DOH An Organisation with a memory)

Delayed or omitted medicine

• NPSA Feb 2010

• 27 deaths,68 severe harms and 21383 others relating to omitted or delayed medicines

• Rate of true harm likely to be much higher

• Cousin et al reported 50% of all medication incidents

Size of the Problem • 5-17% adverse reactions implicated in hospital

admissions in elderly people

• 6-17% elderly patients experience adverse drug reactions whilst in hospital

• NPSA 2007 adminissions for ADR cost £770 million

• Cranshaw et al 2009 Anaesthesia 2009, 64;1317-1323 drug related medical errors cost £ 5 million in litigation costs

EPMA Reported Benefits • Legible prescriptions

• No missing drug charts

• Time saving( rewriting charts)

• Remotely prescribe and review charts

• Imposition of protocols, (antibiotics, VTE)

• Improved audit and surveillance

• Electronic ordering( reduced error rates, more timely dispensing)

EPMA Benefits Ahmed et al Clinical Pharmacist May 2016

• Wide variation in country, type of institution, inclusion and exclusion criteria, classification of error, reporting of errors and systems implemented

• EPMA associated with reduction in medication errors RR 0.46 (CI .035-0.6)

• Not all studies found benefit some found no benefit or increase in harm( Paediatric ITU)

Benefits Nuckols TK, Smith-Spangler C, Morton SC, Asch SM, Patel VM, Anderson LJ, et al. The effectiveness of computerized order entry at reducing preventable adverse drug events and medication errors in hospital settings: a systematic review and meta-analysis. Systematic Reviews. 2014;3:56-.

UK Studies

Study (year) Time of study Hospital Clinical setting Patient

population

System

evaluated System type Functionality Study design

Outcome

measures

Evans et al.

(1998)[26] 1996

The John

Radcliffe

Hospital, Oxford

Intensive care

unit

Critical care

patients

Hewlett Packard

CareVue patient

information

system

Commercial No CDSS Before and after

study

Accuracy,

completeness of

medication

orders, time

Mitchell et al.

(2004)[27] 2002

Southmead

Hospital, Bristol General surgery No restriction

Clinical Manager

3.0A, iSoft UK

PLC

Commercial No CDSS Before and after

study

Medication error

rates

Shulman et al.

(2005)[28] 2001– 2002

University

College

Hospitals,

London

Intensive care

unit

Critical care

patients

QS 5.6 Clinical

Information

System, GE

Healthcare

Commercial No CDSS Before and after

study

Medication error

rates

Franklin et al.

(2007)[29],[30],[31] 2003– 2004

London teaching

hospital General surgery No restriction

ServeRx V.1:13,

MDG Medical Commercial No CDSS

Before and after

study

Prescribing error

rates, medication

administration

error rates,

confirmation of

patient identity,

staff time

Problems • Implementation Key,

• Integration with other systems( Paed ITU)

• Usability

• New errors

• Work arounds

• Managing interface between other systems and paper

• Time/ Efficiency

Hywel Dda University Health Board monthly rolling 6 month rates of C.difficle per

100,000 population

6 month rolling rate of C.difficle/100,000 population

JAC v5.1 EPMA report screenshots

Live webpage for pharmacists to identify their ward patients requiring medicines reconciliation, those on high risk drugs and missed doses in the last 24 hours

Antibiotic section of trial drug chart

• Individual consultants’ clinical freedom still takes precedence over corporate clinical

responsibility, and prescribing practice is seldom reviewed systematically. Only 9 of 105

consultants surveyed reported that prescribing practice formed part of their regular

performance review meetings with clinical directors.

• Information systems have shortcomings: only 17 of 105 consultants surveyed felt that

they receive adequate information about how their prescribing practice compares with

colleagues in their specialty. Most data that are available relate to the cost of medicines,

without proper consideration of their efficacy or health outcomes.

Data and Information

Summary

• Evidence that E prescribing systems contribute to reducing medication errors

• Will only do so as part of a systems approach

• Critical function will be easy of sharing information and collection of data.