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The report will highlight that to enhance technology in clinical setting is not easy. It required lot of support and resources. In-addition technology cannot be successful without well organized plan. It requires long term planning. This report will provide the overview of pilot implementation of electronic medication administration record (eMAR) system. Health care providers need to understand the importance of eMAR & its role in improving patient care safety. This system will help to increase patient safety and have extremely positive impact on hospital reputation. It also helps to decrease medication errors and adverse drug reaction via safe medication administration. It also helps to save printing cost. Pilot implementation of the system assist in identifying issues related to medication administration error in hospital setting. Thus, help to understand how IT processes help to enhance safety. It further helps to understand analyze benefits of the system and how IT facilitates can reduce the chances of error by having robust computerized system. This paper helps to identify users' anxiety to accept the IT systems and little modification in programming helps to get positive outcome. This paper investigates - why IT systems are unsuccessful and suggest computer literacy and simple modification and technical support to users will help to expedite the process to achieve everlasting solutions to provide quality and safe care to the patients
The quality of patient care and safety is one of the most significant aspects of health care sector. Nursing and medical professionals face increased need of using information technology in day to day operations with an overall aim of improving the quality of care by increasing patients' safety. Currently, hospitals facing patient safety issue related to medication administration. Numerous studies conducted to identify number of medication administration error. Stoppler (2006) pointed it as "Approximately 1.3 million people are injured annually in the United States following so-called "medication errors". Chiang (2008) supported this issue as "Medication errors have been a major concern of patient safety initiatives for all health care systems of the world". Internationally health care facilities are struggling hard to increase patient safety via safe medication administration, because existing paper base medication administration record process is not safe and presented with large number of errors. Russo, (2007) stated that, current paper based medication administration record (MAR) is an inefficient process with no decisive workflow, that places needless stress on nursing staff and lead to illegible entries can resulted in medication administration errors. Therefore, to maintain the quality of drug dose administration and to prevent medication administration errors, electronic medication administration record (eMAR) system, is found to be significant. Few studies suggested that eMAR is a bedside medication administration recording tool providing new levels of recording medication administration activities by dropping error rates and making the administration of medications safer for patients. This report aims to outline the background to implement eMAR system, process of implementation, strength & weakness of newly developed system and potential benefits on complete implementation to develop insights about newly developed electronic system for medication administration record.
At my institution in 2006 during Joint Commission International Accreditation (JCIA) survey, auditors were not able to find out the administration record of one of the drug of a patient. This generated a thought to have electronic records for all the care provides to the patients. Malloch (2007) highlighted the need of electronic record as:
"Three specific applications within the electronic record-computerized physician order entry (CPOE), electronic medication administration records (eMAR), and clinical documentation-are impacting patient safety in numerous ways by decreasing incorrect and unnecessary treatments and medications, as well as improving the timeliness of careâ€¦.The benefits from these 3 applications vary, depending on the implementation sequence; some organizations implement each application as separate initiatives, while other organizations have implemented all 3 applications simultaneously". (p. 159)
Consequently our organization decided to initiate each application separately. CPOE for medication prescription, dispensation and medication order review had already been implemented in July 2005. Therefore higher management decided to design and develop in-house system of eMAR for safe medication administration as an initial step towards electronic patient record. The purpose was to eradicate manual MAR and replace with eMAR since current paper based MAR sheets had following subsequent issues:
Manual administration record are more prone to error
Prone to being lost as difficult to manage paper
Utilizes large amount of paper
Not meeting the JCIA requirement
Administration record not available after discharge
Data retrieval is difficult from paper based MAR Sheet
Paper records are frequently lost & unorganized
Sloppily written record lead to legibility issues
Mekhjian et al (2002) found that manual medication administration charting resulted in a transcription error rate of 11.3 percent whereas transcription errors were completely eliminated via eMAR. Further literature supports that the most common errors reported were administering drugs at the wrong time or neglecting to administer drugs at all. "eMAR provided the framework for improvements in patient safety and in the timeliness of care". (Mekhjian, 2002). Bates & Cullen (1995) suggested that 78% of errors leading to drug errors are due to inadequate information management system of eMAR". Furthermore, eMAR has gained a foothold in inpatient settings to support medication administration safety. It prevents paper records prone to being lost, incomplete, or misread. California Institute for Health Systems Performance report highlighted that upto 38% of inpatient medication errors occur at the administration stage (Miller et.al, 2001)
Solution: Electronic Medication Administration Record System
Safe medication administration is one of the most important elements of care. During hospitalization nurses are responsible to administered medication safely to the patients. This activity is performed multiple times in a day for an individual patient. It is a complex process therefore accurate documentation of the medication administration is extremely important. Jylha & Saranto (2008) cited:
"The complexity of the medication management process exposes it to errors, and medication errors can occur at any point in the medication management process. A survey recently conducted in a Finnish hospital showed that more than half of reported adverse events (66%) were medication errors, most of them relating to documentation (33.6%)"
However, manual MAR had lot of issues related to patient safety and could lead to adverse drug events. Thus, organization decided implement for eMAR because it allows nurses to manage medication administration efficiently as it has the potential to make the administration of medication safer for the patients by reducing error rates (Westbrook, 2007). Therefore following steps were taken:
eMAR task force developed to explore the need of technology including hardware & software
Group reviewed current medication administration process and developed flow diagram for expected system
Visited different hospitals in USA to develop understanding of the system and it's flow
Conducted regular meeting with ISD for system design and development
After having vigorous exercise team identified that eMAR could not be implemented completely without right patient identification and right drug identification. This system is heavily dependent on admission and pharmacy system. Therefore bar-coded wrist band & bar-coding unit dose system would be pre- requisite. Consequently sub-group was developed to explore bar-coding system for different applications. The purpose to incorporating bar-coding in health care setting is to improve the quality of care by reducing medical error and by decreasing the cost of care for the patient. Thus, admission and pharmacy departments had been involved for bar-coding implementation. After multiple sitting and cost analysis, group decided to break eMAR implementation in 3 different phases
Phase 1) Implementation of Barcodes:
Patients Armbands for right patient identification for all the inpatients on arrival from admission department
Bar-coded medication labels for identification of "5 rights" include right patient, right drug, right time, right dose & right route. Further pharmacy system generates medication administration schedule; this schedule will be foundation stone for eMAR.
Phase 2) Medication Trolley
Purchase new medication trolleys with Laptop having wireless connectivity & barcode reader to view active drug list due at specific time, to follow 5 rights
Phase 3) Online MAR
Develop software of eMAR to eliminate manual MAR and initiate online entry after administration in computer to eradicate paper
How this will work
Nurse will identify the patient by scanning wrist band
Nurse will then scan the Medication Cassette Bin of respective patient
First RIGHT will be identified at this point
Nurse will then scan the Medication Labels
Remaining four RIGHTS will be identified at this point
Nurse Administer the Dose to the Patient
After Administration, Nurse will put her "Signature" electronically into the system
Thus above requirements were communicated to the senior management. Consequently due to lack of resources implementation of all above requirement were not possible at once because huge amount of money is required for barcode implantation in admission and pharmacy department and sophisticated medication trolley with laptop & barcode reader.
Therefore, team determined to implement eMAR successfully, with good outcome and within the resources provided, all above phases need to be implemented step by step. That's why 3 sub-groups have been developed to initiate the work for each activity. Group 1 will work on Bar-coding planning and implementation. Group 2 will be responsible for purchasing of sophisticated medication trolley and group 3 will work on software development for electronic administration entry for medication.
However, phase 3 of aforementioned plan was to be implemented first as it only required in-house software developments with no extra cost involvement and further built on existing CPOE system. Therefore, group 3 comprises of nursing and information system department (ISD) team work together to design and develop the system. ISD developed first template of eMAR in December 2006 and presented to nursing management team for feedback, they suggested few modifications. Modified version presented to them again for re-evaluation in February 2007. Afterward, pilot implementation was done in 5 beded cardiac step down unit in April 2007. Same was replicated in other cardiac stopdown units. Subsequently it was replicated in other units depending upon the availability of computers. Therefore, 06 desktop computers, 20 wall mounted computers in intensive care units, 2 mobile trolleys without medication bins & 2 laptop mounted medication trolleys were provided in nursing units to cover 153 beds out of 520 beds. This covers 30% of total admitting patients.
This phase will help to overcome issues of legibility, decrease chances of data lost as not need to manage paper since no paper is required. It helps to meet the JCIA requirement as data retrieval is easy and able to find out administration record. In-addition this will help to have ontime administration record and nurse need to sign the medication after administration and system will capture administration time which will further help to indentify wrong time administration, delayed administration and miss dose administration. Through this phase patient safety issue is still not resolved as identification of "5 rights" is achieved manually because bar-coding is yet to be implemented.
However, further implementation discontinued after July 2008 due to resource limitation for computerized laptop based eMAR trolley & barcode implementation. In-addition few reservation for further implementation related to multiple & frequent system breakdown and users resistance for further implementation was also highlighted. Therefore, eMAR task force re-collected to discuss and resolve above concerns to promote further. They identified following issues:
Issues related to system functionality
System performance/ shutdown issue.
Issues related to limited hardware availability
Training issue and computer literacy issues
Users resistance as system force them for ontime documentation whereas paper base MAR have provision to sign the administration record as per their own accord
On other hand group 1, barcode team implemented bar-coded armbands for all the inpatient. Now only medication label to be bar-coded is pending, for that label has been designed and approval has been taken from nursing users and pharmacy. Bar-coded label printer is to be purchased and pilot testing of barcode label needs to be carried out.
Group 2 representatives explored different eMAR trolleys available in the market to identify the most suitable for our working environment. Our requirement is light weighted small trolley with 10 medication bin as 1 nurse is assign to 10 patients. Finally it was decided to purchase Atromick Medication Trolley. Purchase order was generated to have sample trolley to pilot. Trolley has been piloted successfully and received positive feedback from nursing users. Therefore, it was decided to purchase 72 more trolleys as required by nursing units. 46 trolleys will be purchase by October 2010 and remaining will be purchased in 2011.
System feedback after pilot implementation
Information technology seems to be more proficient and provide transparent alternative to manage issues/concerns smoothly. After pilot implementation of in-house developed eMAR software and Atromick medication trolley few strength and weaknesses were identified. We identified that most of the users in our hospital are not well computer literate. This lead to increase resistance and they prefer to use manual system. Another most important issue is lack of interest from some of the nursing managers. They even not agreed to initiate the pilot project and the main reasons were lack of staff, lack of computer literacy, lack of hardware availability on nursing floor and they felt it would increase staff workload. Their concerns were well taken and computer training had been provided to nursing staff before initiation and on regular basis as well. Moreover, extra computers have been provided on nursing floor before pilot implementation. Nursing director is working hard to increase number of staff but it's difficult as currently nurses' turnover rate in our organization is 17%. Lastly management group was explained that it definitely increase some workload initially but it save nurses time currently utilize on maintaining paper record and data retrieval as it will be more transparent. It also increases safety of the patient and their record and have ontime documentation of drug administration. Thus, pilot project has been put into practice for 30% of hospital beds. The pilot project helped us to be acquainted with the weaknesses of the system which includes:
Lack of material resources & human resources
Gaps in software programming i.e. initially all the stat orders and single dose order automatically disappeared from the screen with drug stop time. This created frustration among users as they were not able to mark administration for pre & post transfusion drugs, chemo therapy drug, pre & post operative drugs. Another gap is related to infusion screen as nurses have to sign infusion record every hourly which increase their workload.
Multiple time system got stuck/ slowdown/ non functional endorse resentence of users as they feel whole process is very slow
Users highlighted that system is not user friendly
On multiple occasion users identified that same drug appears twice on the screen. On investigation it was find out that it's because physician enter new order for same drug without discontinuing the previous one. Therefore, modification is required in CPOE system.
Unsatisfactory technical support
Lack of training
System usually found to be slow which lead to increase administration recording time
Beside, this one of the most important issues is resistance from users' side as it increases their workload as well as their accountability, because paper base system has provision to sign the administration record as per their own accord. Whereas, electronic system increase obligation for ontime documentation. Another most important weakness is related to patient safety issue as bar-coding system has not been initiated yet and users' relays on manual identification of 5 rights.
However, in conjunction with above resistance, users' satisfaction survey conducted in July 2008 showed 79.9% satisfaction of users with the system. The results appear with positive feedback but they highlighted area for improvement. Their feedback enclosed request for multiple modification, for instance separate screen for cyctotoxic drug administration as this required to mark start and stop administration time with comments as these drugs administration time last for hour. Demand to generate multiple reports to view administration record, miss dose administration record, administration record of discharge patient, administration report of particular drug etc. Primarily system starts with single screen for all type of administration i.e. intravenous infusion, PRN and routine medication which overcrowd administration screen and create confusion. Therefore, requested to develop separate option for each. In-addition modification was requested for infusion screen as current option requires to sign infusion every hourly.
Survey also highlighted some of the strength of the system pointed out by users which include:
System helps users to easily identify numbers of doses administered to particular patient for specific drug as data retrial is extremely easy, though sometimes it takes time due to slowness of the system but it's faster than manual process as data retrieval is difficult with paper base system.
In addition it helps users to identify miss doses, delayed administration and skipped administration.
It decreases utilization of paper and save printing cost.
It helps to identify reason for delayed & miss dose administration
Administration screen appears with current drug only i.e. due for administration for next dose time.
System frequently update with changes in CPOE system and has good interface with pharmacy and admission system
System is easy to operate and output (Administration reports) data from system is reliable and accessible
System appears with detail information regarding drug including drug name, ID, required dose, dose time, route, frequency, star time and stop time, drug comments if any for safe administration.
System is provided with dictionary based comments column for nurses to enter administration comments if any, in case of delayed, missed & early administration.
Paper base system utilizes nurses' time to print medication label on drug review and then need to paste them in MAR sheet. This system omits all above and reviewed order in CPOE system automatically appears on eMAR screen for administration.
Thus, many nurses found this system very effective the only concern is related to more time required at entry level. We identified that nurses with good computer skills are more positive towards IT systems. Chiang (2008) cited that "Studies have shown that, for instance, nurses found that the IT system was good in aiding prevention of medication errorsâ€¦.but required a lot of time in operating the system".
Potential benefits of the system after complete implementation
eMAR system can improve the administration record and will able to provide accurate administration time of the drug. It advances patient safety by right patient and right drug identification via bar-coding system. To elevate further safety option has been developed in a manner to mark administration after actual drug administration to the patient as system is not provided with any go back to your old ways option, which will help to increase reliability. System has been provided with mandatory option to enter comments for delayed administration or miss administration which will help later to identify causes and corrective action can be taken to improve business. Besides the safety of patient and its data, other supplementary benefits are cost and saving of storage space. Currently our hospital utilize huge amount ($15857/annum) of money for storage space. Although, these potential benefits are currently not very visible but it will be apparent with complete computerization of patients' record. In addition an electronic system gathers all at one wave length and has standardized practice. This will provide opportunity to have good interface with national and international systems later. To get most out of it nurses suggested to provide medication order review screen & drug formulary on eMAR system to save nurses time for multiple login. Kuperman & Gibson (2003) cited "This technology can yield many significant benefits and is an important platform for future changes to the health care system".
Patient safety is our main objective while working in clinical setting. Therefore, technology needs to be adopted to enhance safety. This will help to progress further. We all need to work continue to enhance computerization and involve information communication technology in hospital setting. Our organization actually works hard to achieve eMAR to increase patient safety and by 2011 we will certainly achieve our target to reduce medication administration error. Above report shows that eMAR system helps to increase safety, decrease medication administration error and safe printing cost. On top of it system will avoid wrong time error and have ontime documentation.