The transition from paper documentation to an electronic medical record (EMR) system with an integrated computerized physician order entry (CPOE) and the use of barcode technology has revolutionized the way that nurses administer medications and document this intervention. This project was successful with the reduction of the medication error rate by 74% from the baseline which exceeded the target of 70%. Implemented over the course of two years, a project team led the different activities within the phases of planning, implementation, and evaluation. The project also resulted in a workflow that enhanced adherence to the six rights of medication administration. The purpose of this paper is to discuss the project findings more in-depth.
Prior to the project, paper charts were used to document and communicate information about the patient including medication orders. A paper Medication Administration Record (MAR) was created for each patient by nurses and contains the medication name, dose, route of administration, time of administration, and frequency. Nurses referred to the MAR when they prepared medications and put their initials on it to indicate that the dose was administered. The nurses confirmed patient identity by comparing patient information on the MAR and the name and date of birth indicated on the patient’s wristband.
However, this paper documentation system and system of medication administration has been associated with medication errors based on a workflow analysis. A review of incident reports on medication errors showed that illegible handwritings and the use of non-standardized abbreviations caused wrong medication and wrong dose errors as was also shown in the literature (Keers et al., 2013). This happened especially when nurses failed to verify with the physician and chose to make erroneous transcriptions onto the paper MAR. Moreover, the 6 rights of medication administration are the standards of practice (Potter et al., 2013). A survey of nurses was performed to determine how well they adhered to this standard. The results were 47-52% adherence to right medication and right dose checks, and 29-33% adherence to right patient, right time, and right route verifications.
The meaningful use of technology includes integrating its use to enhance adherence to standards of safe medication practice (AHRQ, 2013). For this reason a reduction of the current medication error rate was one of the goals of the adoption of the EHR and the barcoding system. The workflow in relation to medication administration has changed immensely with the integration of several safety mechanisms. The success of the workflow can be attributed to the engagement of all stakeholder disciplines evidenced by the creation of a multidisciplinary project team as was also shown in the literature (Detwiller & Petillion, 2014). Nurse informaticists played a crucial role in the team by bridging information technology (IT) and health care. Furthermore, Detwiller and Petillion (2014) recommended a participatory approach that involved direct care staff in the planning and implementation which as adopted by the project team. The workflow was subjected to a pilot first and improvements were made prior to full implementation.
The workflow begins when a physician orders a medication through the CPOE, order sets are available to choose from and alerts ensure that patient allergies and other contraindications have been considered. The orders are then checked by pharmacists for appropriateness of dose or form and are prepared, labeled, and stocked in the medication carts. Adhering to a protocol based on the 6 rights of medication administration, nurses compare the electronic MAR to the medication when they retrieve it. This prevents a wrong drug, dose or route error. Using the barcode system at bedside, nurses scan their badges to log on and scan the patient’s wristband which leads to the patient’s MAR appearing on the screen. This prevents a wrong patient error. The nurse then chooses the medication that is due, scans the medication, and administers it. An alert pops up on the screen if the nurse chooses by mistake a drug that is not yet due or if the scanned medication label and the chosen medication on the MAR do not match. These further help to reduce medication errors. Only then can the nurse document that the drug had been given by scanning the patient’s wristband again which then allows the nurse to choose another medication or log out. This ensures right documentation.
However, it was recognized that information technology can enhance medication error prevention but that it cannot, by itself, address the issue. For this reason, a huge part of project implementation was spent on staff education and training which encompassed EHR use, barcode technology use, standards of care in medication administration, and the new workflow. Didactic learning activities and simulations were conducted by nurse informaticists and educators. Continuous support was given as well until the staff developed confidence in using the new technology and in adhering to the new workflow and protocol. The reporting of medication errors was encouraged with emphasis on use of such events as a learning opportunity in further improving systems and processes.
Monitoring was very important in creating awareness about progress and potential roadblocks and was managed and coordinated by the nurse informaticists. The medication error incidence, rate, and type as well as the medication and patient involved and the outcomes were monitored using standardized definitions/formulas and a tool to extract data from incident reports. Protocol adherence was likewise monitored using MAR data and random observations. Run charts were created for continuous data to monitor monthly progress. The information derived from data prompts investigations to ascertain flaws in the system and their causes (AHRQ, 2013). One example was the lower number of barcode medication scans made and the actual number of medications administered. An investigation led to the discovery that some nurses were not actually using the barcode scanner. The barriers to use were subsequently discussed and actions taken to address workarounds.
The experience demonstrated how health IT can be used meaningfully to improve patient outcomes. Full adherence to the medication administration protocol increased from 24% one month after implementation to 97% eight months after. The medication error rate went down from 7.3% of all medication administrations to 1.2%. Nursing informatics played a crucial role in the planning, implementation, monitoring, and evaluation of the project. Nurse informaticists bridged IT and health care knowledge in helping design the EHR system and served as curriculum developers and educators. They also led data monitoring to generate information and knowledge used to support decisions to further improve protocols and to evaluate the impact of health IT implementation.
References
Agency for Healthcare Research and Quality (AHRQ) (2013). Practice facilitation handbook. Retrieved from http://www.ahrq.gov/professionals/prevention-chronic- care/improve/system/pfhandbook/mod17.html
Detwiller, M., & Petillion, W. (2014). Change management and clinical engagement: Critical elements for a successful clinical information system implementation. CIN: Computers, Informatics, Nursing, 32(6), 267-273. doi: 10.1097/CIN.0000000000000055
Keers, R. N., Williams, S. D., Cooke, J., & Ashcroft, D. M. (2013). Prevalence and nature of medication administration errors in health care settings: A systematic review of direct observational evidence. Annals of Pharmacotherapy, 47(2), 237–256. doi: http://doi.org/10.1345/aph.1R147
Potter, P.A., Perry, A.G., Stockert, P., & Hall, A. (2013). Fundamentals of nursing (8th ed.). St. Louis, MO: Elsevier.
