Running Head: MEDICATION ERROR: TECHNOLOGICAL ADVANCES

MEDICATION ERROR: TECHNOLOGICAL ADVANCES Victor J. Lei Northeastern University

MEDICATION ERROR: TECHNOLOGICAL ADVANCES

Abstract Technological advances have changed the way many hospitals and pharmacies operate over the years. It is important to note that the change has come from thorough observation and analysis of current systems. In the healthcare field, medication errors are an important area of focus that needs constant improvement. Studies have been produced to measure the relative improvements on how technology has decreased the amount of medication errors made. Technology within the hospital and outpatient setting includes all levels of medication handling. It is important to see and observe the growth of such systems to help better understand how to further improve.

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Introduction Healthcare professionals try their best to provide the most optimal care to their patients. Whether this comes from a thorough diagnosis or reduced wait times in the emergency rooms, improving patient care is a critical responsibility in healthcare field. Unfortunately, people make mistakes. It is unrealistic to expect healthcare professionals to have a zero percent margin of error, especially when healthcare professionals are being asked to work faster and increase patient volume. Thus, it is important for them to reduce their error as much as possible. Within the pharmacy department, there are many avenues where patient care can be affected. Pharmacists must worry about drug safety and medication errors. Technology has responded to this concern with new methods that have helped decrease medication dispensing times and increasing drug location tracking. Corporations like Pyxis and Omnicell, which focus on medication management, have changed the way pharmacy departments operate entirely. They have introduced carousel fill machines, and automated dispensing cabinets and drawers. Including the previous mentioned machines, technology has advanced to help significantly decrease the amount of medication error. With an in-depth discussion of what are medication errors, the technological advancements and pitfalls give insight on how one must operate and be aware of for the healthcare professional. Types of Medication Errors A Medication Error is an overarching term that describes a discrepancy between the patient and the correct drug intended for the patient. From that, medication errors can be broken down into 4 categories: prescribing, dispensing, administration, and monitoring (Lombardi 2000). For the first, prescribing errors occur when there are hard to read or wrong drugs

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prescribed to a patient. Other issues include transcription errors from pharmacists and technicians. In dispensing errors, the mistake occurs between the handling of the drugs from the pharmacy side. As Figure 1 show, there are many occasions where a drug can be mishandled.

Figure 1 (Cheung, Bouvy, De Smet 2009) It is important for pharmacy workers to understand where these errors can occur and how to deal with them when they occur. If left untreated, serious drug adverse reactions could occur to patients if dispensed and administered the incorrect drug. This leads to a third potential error, administration error, which occurs while the drug is handled for the nurses or physicians who give the medication to the patient. It is important for healthcare workers to make sure they are administering the right drug to the right person. The final fourth type of medication error is monitoring, which is the last checks to see if the patient is receiving the correct dose and medicine.

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Technological Advancements Medication management companies have focused by looking at the many avenues where medication errors may be reduced. Some have focused on the transcribing of prescriptions. Others have focused on the dispensing and administration tracking machines. One of the most influential developments in medication management is Computerized Physician Order Entry (CPOE), which was created to help eliminate difficult to read handwriting, transcription errors, and ensure right prescriptions were paired with the right patients. Software would be utilized by mainly nurses and doctors, while being reinforced by pharmacists. Information input would then relay over to pharmacy information systems. Research indicates, computerized physician-order entry has been shown to reduce the incidence of serious medication errors by 55% (Poon et al. 2010). By keeping many of the interactions on an electronic media, healthcare workers can consistently see and understand where the order is in the process. This helps keep healthcare workers up to date on the handling of their medication to the respective patient. Such CPOE systems usually do not act alone. They in fact, often are paired with other information systems to help keep the information on a digital level and at all levels track medication from point a to point b. With this the development of barcodes has been essential. Barcodes on medications became mandatory by the Food and Drug Administration in 2006. Hospitals have, since then, begun implementing bar-code technology into their dispensing workflow (Poon et al. 2005). Barcode technology has had tremendous influence on the way healthcare practice operates. It permeates many levels of medication handling. From the beginning, prescriptions entered through a CPOE are given unique prescriptions that are specific to the prescription and patient. Medication management companies like, Omnicell and Pyxis,

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utilize this in combination to the drug barcodes to help picking and dispensing of drugs. Machines with implemented software can categorize and identify if the correct drug is picked for the specific prescriptions. In the realm of dispensing, drugs can be scanned with prescription labels to make sure that they match up. This can go further when automated dispensing machines are stocked and drugs are required to be rescanned again to make sure the right drug is in the right location in the machine. From there, nurses and doctors can enter the machines and receive the correct drug for the correct patient. However, once the drug leaves the machine and enters the hands of the nurse or doctor, there leads to a potential error in administration. Error in administration would often occur with incorrect dosing or incorrect patient with the respective drug upon patient receiving the drug. Point-of-Administration (POA) systems were created as a result. POA systems ensured the right dose of the right drug was administered via the right route at the right time to the right patient (ASHP 2004). Verification would be created at specific checkpoints were drug or patient information could be mishandled. Barcodes were applied to patient wristbands and their specific code would entail the correct information about their list of approved medications. Electronic prescriptions would also have their own set of barcodes that would check if the barcodes on the drug and the prescription match, when they were delivered, and when they were administered. The pitfalls of the technological advancements and common mistakes made With the advancements, new problems arise in the implementation of the systems. Bar code technology has definitely decreased the amount of errors, but the system is not perfect. Often times, there are instances of unreadable drug barcodes or human error in scanning the drugs. Other times, some prescriptions would involve dispensing multiple vials of a drug where

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only one drug would be scanned rather than all. Such limitations can cause mistakes in the dispensing of drugs. CPOE still is in a developmental phase and requires immense amounts of intervention. James Carptener, R.Ph., breaks down the difficulties of CPOE implementation and development, Implementing CPOE is challenging because of the complexities of medication orders and the clinical decision support that is required. Every possible type of order must be accommodated. Order communication channels are complex and communication is not necessarily linear. Professional knowledge and information are not discrete bits of data that can be stored and retrieved at will and they do not map in a simple manner onto other schemata. (ASHP 2004) The difficulties of implementation alone make utilizing CPOEs cumbersome, but also increase the amount of potential medication errors. It would be expected for hospitals upon first few months to have more errors, but eventually for the errors to decrease with the increased experience and knowledge of the system. Such problems can even leak into the dispensing realm. When an order is entered into a CPOE the information is carried to the appropriate machines that allow for the pharmacy to pick and dispense the entered drugs. Dispensing errors can occur even with the new technology implemented. Simple errors include the wrong drug restocked in the wrong location. Others could be dispensing a higher dose than what is prescribed due to limited stock of the drug within a pharmacy. One of the most important limitations would be caused from barcode technology. As pharmacists note, Pharmacy staff are frequently interrupted to address scanning problems and other unresolved issues. A variety of different bar-code formats are in development and reading the newer formats will require updated scanning equipment. Decisions also were made

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about scanning procedures for certain products (e.g., bulk items, such as

topical

medications and inhalers and floor stock items, such as heparin flushes). In addition, education is necessary because nurses often do not recognize that floor stock is a medication, the administration of which needs to be documented. (ASHP 2004) Technology, though helpful, often include little hindrances like the previously describe. Barcode technology does have limitations in the parameters that set. For improvement to occur, such systems including that of CPOE and on other levels of medication handling, one must view the process systematically. Six Sigma as an Approach to Improvement Technological advancements come with their own set of problems. One interesting way of tackling some of these common problems is to utilize Six Sigma. Six Sigma is a set of strategies and techniques that are used for process efficiency and reducing defects in policy and procedure. It can be used to help dispensing errors when utilizing the multiple machines and software within a hospital pharmacy department. For this to work, it requires heavy statistical analysis. This process can be broken up into 3 sections: measurement phase, analyze phase, and improvement phase. One hospital was able to decrease their errors by 230 errors per million. The implementation of Six Sigma also helped pharmacists realize and understand the workflow that they utilize and where errors could occur. They became more open to tackling medication error problems and understood the importance of them (Chan 2004).

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Figure 2 (Chan 2004) Process flow maps are important to help view and analyze where errors can occur. From these maps, information can be extrapolated to try to piece together potential solutions to improve on reducing medication errors. Conclusion There is no doubt that medication errors have been reduced by technological advancements, but it is important to not forget the common pitfalls that can attribute to many errors. A technological system is only as good as the compliance of the team utilizing the technology. So education and communication should be implemented between all healthcare workers to be able to utilize the new technological advances and continue to decrease the amount of medication errors that can occur.

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Reflection This paper was very difficult for me to organize and break down. I found myself trying to discuss/argue too many things. However, I hope I was able to break down the information in a relative cohesive manner. I did notice that I found myself pulling a great deal of information for the ASHP mid year continuing education piece. I was hard pressed to believe it is a popular source but had difficulties citing it all. I would place this in my portfolio because it relates to how technology has changed the many aspects of medication handling and errors.

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References ASHP (2004). Improving medication safety in health systems through innovations in automation technology. ASHP. http://www.hospitalrx.com/pdf/ASHP%20Smart%20Pumps.pdf Lombardi, T. P. (2000). Closing the loop implementing quality improvement processes and advances in technology to decrease medication errors. Medscape. http://www.medscape.com/viewarticle/408564_4 Chan, Agnes L. F. (2004). Use of six sigma to improve pharmacist dispensing errors at an outpatient clinic. American Journal of Medical Quality, 19(3). http://ajm.sagepub.com/content/19/3/128.full.pdf Cheung, K., Bouvy, M. L., De Smet, P. A. G. M. (2009). Medication errors: the importance of safe dispensing. Br J Clin Pharmacol. 67(6). doi: 10.1111/j.1365-2125.2009.03428.x Poon, E. G., Cina, J. L., Churchill, W. W., Mitton, P., McCrea, M. L., Featherstone, E., Keohane, C. A., Rothschild, J. M., Bates, D. W., Gandhi, T. K. (2005). Effect of bar-code technology on the incidence of medication dispensing errors and potential adverse drug events in a hospital pharmacy. AMIA Annual Symposium Proceedings. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1560475/#__ffn_sectitle Poon, E. G., Keohan, C. A., Yoon, C. S., Ditmore, M., Bane, A., Levtzion-Korach, O., Moniz, T., Rothschild, J. M., Kachalia, A. B., Haynes, J., Churchill, W. W., Lipsitz, S., Whittemore, A. D., Bates, D. W., Gandhi, T. K., (2010) Effect of bar-code technology on the safety of medication administration. NEJM, doi: 10.1056/NEJMsa0907115