electronic prescribing system medication errors: identification, classification and mitigation

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%



Factors Involved Not check Admin History 35% System defaults 30% Alert issues 30% Dual processes 30% Integration 4%


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


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 …


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)…


Withholding Actions

Training scenarios

Education Campaign

Enhancement Vendor / NeMP

Preventing roll out to surgery


Wrong start date/time Transcribing

New workflow = Defaults to start medicine at NEXT available dosing time


Wrong start date/time Action

Training Dr scenarios Educate

Nurses about doctor workflow, especially defaults Pharmacists focus on timing issues for new

admissions


Nurse education about prescriber defaults


Strength / Dose mismatch New workflow = Prescription includes strength


Strength / Dose mismatch Action

Training scenarios Education

Doctors about strength /dose display in Admin screens

Campaign for recommended workflows



Nurse Workflow Education Select medicines from Pyxis in “Administration” screen CHECK medicines in “Confirmation” screen (reads like

a sentence)



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)



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


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


Not checking Administration History Action

Enhancement Last dose administered viewable in Administration screens Delivered v8.1.1


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


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


Wrong Drug New workflow = Selection of medicines from list of forms & strengths


Wrong Drug Action

Training Screen shots of common mistakes Importance of checking full screen


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”


Medicine Events for high risk or error prone drugs

warfarin morphine oxycodone diltiazem insulins metoprolol


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


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”


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


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


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

[email protected]

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


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


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


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%



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%


Warfarin new workflow Medicines arranged in “tabs” by script type Editing dose workflow different from other

medicines Had to select brand (incorrect default)


Action Warfarin

Rules to alert infrequent prescribers to unusual workflow

Removal of “ALL” tab Enhancement

Change default configuration to brand “unspecified”


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%)


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


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”


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


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


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


Medication Errors

electronic prescribing system medication errors: identification, classification and mitigation

Healthcare