eMAR: A process to ensure ontime medication administration and identifying delayed/omission of drug, reason for delayed/omission of medication and user satisfaction with eMAR as compare to MAR at AKUH, Karachi Pakistan
Introduction & Background
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. The 21st century is the competitive age of information, analysis, implementation and learning. Information technology currently plays a large role in patient's safety and enhances the use of electronic prescription and dispensation. However, only having electronic prescription and dispensation is not enough, organization should have electronic administration for patient safety. 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 mistakes (Michael, 2007). Therefore, to maintain the quality of drug dose administration and to prevent medication administration error, electronic medication administration record (eMAR) is found to be important as "up to 30% of inpatient medication errors occur at the administration stage" (FitzHenry et al, 2007). 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. The Aga Khan University Hospital (AKUH) is responsible for providing the quality patient care according to the standards that have been set. One way to achieve these standards is to integrate information technology in health care settings. AKUH is currently functioning with computerized physician order entry (CPOE) system for medication prescription and dispensation which needs to be further enhanced by the implementation of eMAR. We have identified that number of medication administration errors are increasing with time and high number of delayed /omission of errors have been notified in the last 3 years i.e. 2007, 2008 & 2009 and total number of incidences related to omission were reported are 118 & incidence related to delays were reported are 35. Therefore, implementation of eMAR became a necessity to prevent omission & delays administration and to have ontime documentation. Thus this study will focus on ontime medication administration record with electronic system and to identify delayed (wrong time error) & omission of drug via electronic administration to prove eMAR is a right process for drug dose administration. Further this study with compare previously reported medication incidence related to wrong time error and omission of drug to identify weather electronic medication administration system will help to highlight these type of issue more obviously as we assume the medication error related to delayed/omission are under reported.
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This study is very significant for me as upto my knowledge the process of electronic administration system not yet initiated in any of the hospital of Pakistan and no such study have been conducted in my area of work and it would be unique kind of study. My interest in eMAR arose from my experience and interaction with medication nurses and the number of incidence reported regularly about delayed administration. At the same time as reviewing the incidence reports, I identified large number of medication errors related to omission of drug. Further, paper base MAR sheet has fixed time to mark administration and thus creates difficulties in identifying delayed administration.
The purpose of the study is to highlight that eMAR would ensure on time documentation, save time and cost and identify wrong time administration error, omission of drug and the reasons for delayed/omission of medication in order to decrease the number of medications mishaps. The study will also help to explore the advantages and disadvantages of eMAR v/s MAR, will help to analyze users' satisfaction with electronic medication administration system at Tertiary Care Hospital and will stand as the basis for further implementation of electronic health record for online nursing documentation.
To identify number of delay (wrong time error) administration error before and after eMAR implementation
To identify number of omission of drug error before and after eMAR implementation
Always on Time
Marked to Standard
To identify the factors contributing to delay/omission of medication administration
To examine users perceptions regarding medication process, post eMAR implementation
What are the implication of study findings to medication administration process
To identify the reduction in printing cost by implementing eMAR
Medication administration is a crucial nursing task and safety checks at medication administration are critical. Administration errors are increasing day by day and only few of them were identified, because of fewer checkpoints due of manual process. Secondly nurses are alone when they administered medication. (Wright & Katz 2005). Several studies conducted on medication administration error and proven that medication error are very common and regularly occur in every health care setting. Frequency of medication administration error very well proven by (Van Den Bemt, et al. 2007; FitzHenry et al. 2007; Michael. 2007; DeGiorgi et al. 2010; Stoppler. 2006; Chiang.2008 ). Therefore to concentrate on administration error is very important. Leape et al. conducted study in 1995 and concluded that most error occur due to inadequate information management system. Hence my organization also having similar situation and number of medication administration error increasing day by day so we decided to enhance CPOE system of medication by the implementation of eMAR to maintain the quality of drug dose administration and to prevent medication administration errors, via electronic medication administration record system, as it is found to be significant.
Westbrook (2007) stated "Electronic medication administration records provide the potential to make the administration of medications safer for patients by reducing error rates and also by allowing nurses to more efficiently manage medication tasks". (Can add more literature) Since 1995 AKUH working with dot system of CPOE for medication and in 2005 we initiated window based CPOE system. Soon after that we realize that CPOE helps to prevent prescription, transcription and dispensation error whereas administration errors are still there and require having electronic administration system. This vision of CPOE unaccompanied without eMAR not able to reduce medication error. This thought is well supported by many authors in their research studies such as (Mekhjian, et al. 2002; Bates & Cullen, et al. 1995; Robert, et al. 2006). Consequently implementation of eMAR achieved in 30% of all the admitted bed of AKUH, further implementation is under process and will be achieved by June 201l.
Accordingly reviewing literature on similar topic identified that very little study conducted on ontime medication administration record to identify wrong time error & omission of drug. Most of the studies conducted on medication administration error, out of them only few studies include wrong time error & omission of drug for example (FitzHenry, et al. 2005; Bemt, et al. 2007; Tissot, et al, 1999) Bemt, et al. highlighted, medication administration error included wrong time error upto 11% & omission of drug error upto15.2% of total of study outcome. He asserts that most of the administration errors are underreported due to manual process (2007). Allan & Barker 1990 stated "Wrong time errors are generally considered less serious than other errors". This idea is again supported by FitzHenry et al. (2007) He "recommended future study of medication administration processes to determine a classification of medications based on "timing criticality" for administration". Thus my study mainly focus on system generated data from eMAR system which helps to identify wrong time error electronically. Thus electronically achieved eMAR data will compare with incident report data of medication error, to identify number of delayed /omission of drug administration error reported pre eMAR & post eMAR. This identification helps management to reinforce users for ontime documentation as well. National Patient Safety Agency Report highlighted the need to "have the systems that ensure drugs are given on time". Further added that "An area of major concern is where a dose is omitted or delayed. This was the second largest category of medication incidents reported to the NPSA in 2007". On time documentation for medication administration is questionable with manual recording. As manual recording unable to identify delayed/wrong time error as well as omission of drug. litrature
Study conducted by Green et al. (2009) on omission of drug administration highlighted multiple reasons for omission of drugs; out of them 19% of omitted dose appear without any reason for omission. Whereas eMAR in-house developed software of AKUH not allows nurses to omit dose without any comments. Dose remains on nurses' administration screen till comments has been entered and saved. Furthermore, Rogers 2005 conducted similar type of study but not able to provide accurate date on frequency of omission. However few studies conducted on timely administration of antibiotics and more focus provided to ensure on time administration of antibiotics. Whereas eMAR system have feature to capture dose administration time automatically and if any medication administered at wrong time system change its color on the screen and ask for reason for delayed administration.
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Colorado and Georgia indicates "The most common errors reported were administering drugs at the wrong time or neglecting to administer drugs at all".
This research will be using mixed method and research questions would be answer using both quantitative & qualitative approaches.
A quantitative Quasi-experimental study design will be used to identify and analyze all the incidence reported for delayed /omission of medication administration pre eMAR implementation over a period of last 4 years and post implementation data collected from eMAR administration report and incident reporting system over a period of one year i.e. from July 2011 to June 2012 from patient care location of AKUH. Further because of less control on variable, as nonequivalent comparison group, no control group, approach would be applied to conduct the study. The approach of pre & post analysis to identify delayed administration error before system implementation and post implementation will be used. In addition quantitative data collect to identify cost utilization & cost saving. Further post implementation eMAR administration data will be collect to ensure ontime administration. Data will be analyzed using statistically technique of SPSS version 16. Then frequency of error will be calculating by total number of medication error related to delay/omission of drug divided by total number of medication administration.
Users satisfaction with the current system as compare to MAR, qualitative approach will be apply to answer above question. Qualitative data will be obtained by using questionnaires. Written questionnaire will developed to explore users perception regarding eMAR system.
Study Population & setting
For this study population will be registered nurses of the 4 critical care units and 4 general ward unit of the Tertiary Care Hospital. Registered nurses of all above units are trained to use eMAR system and post implementation assessment has been done to investigate wrong time error, delay/omission of drug, reasons for delay/omission of drug & users feedback on the system. This study will be conducted at the Aga Khan University Hospital Karachi, Pakistan as it's my working place and will be convenient for me.
This study plan to conduct at 545-bed tertiary care hospital currently functioning with CPOE without eMAR. Plan to implement eMAR in entire hospital and to conduct post implementation evaluation in 4 intensive & 4 general wards to investigate delayed/omission of medication, to identify reasons for delayed administration & omission of drug, cost saving with eMAR & users' satisfaction with the electronic system. Retrospective study conduct to compare; number of delayed/omission of medication incidences reported via online incident report form (IRF) in 2009 & 2010 along with reasons for delayed administration, identify post implementation data from online IRF system for delayed/omission of medication incidence from July 2011 to June 2012 with reasons for delayed administration, collect data from eMAR system to identify ontime medication administration record and delayed medication administration record (wrong time error) "Delayed medication administration or wrong time error would be all the doses administered one hour before & after its dose time", identify printing cost utilization with MAR & cost saving with eMAR, identify user satisfaction with eMAR system. This comparison of pre & post data helps to analyze weather eMAR ensure ontime administration and helps to identify number of delays/omissions
Data Analysis Plan
Data will be analyzed by using SPSS software. Pre implementation data on medication incidences for delayed /omission of drugs will collect from IRF system. Whereas post implementation data will be collect from IRF system as well as eMAR system to compare. In addition to examine users perceptions regarding medication eMAR implementation qualitative data collect by having structural survey questionnaire and outcome will be reported as effect of study. Similarly Pre & post implantation data on printing cost will be obtain from purchase & supply department to identify the reduction in printing cost after eMAR implementation.
Delay/omission of drug administration incidences will be decrease with eMAR implementation.
There is a positive relationship between medication administration incidence and eMAR system
Aims & Objectives
Study findings will help to improve nursing process of medication administration by corrective action & regular audits. This study will allow us to explore user's willingness for electronic health record system in future for online nursing & physician documentation. This will help institutions to find out the potential problems in electronic systems and different strategies to overcome. Lastly, we examine the probable consequences of electronic systems and suggest further action needed to make the best use of technology to improve the quality of patient care, to save time and to reduce cost.
eMAR implementation in all the patient care location required only 46 Laptops. Out of them 23 required to mount on existing medication trolleys , 20 will be mount on wall between 2 patients in intensive area & 2 mobile cart & I desktop computer in intensive area for eMAR. Mounting required 43 brackets to fix the laptops & 16 wireless access points required for application access
For this study permission will be obtain from ethical review committee of AKUH Karachi, Pakistan and permission from unit management and director nursing services for getting data from electronic system of their location. A written consent form will be developed to obtain users feedback on the system.
Purposed Time Table
Dec 2010 -Jan 2011
Ethical Review by AKUH ethical review committee
Implementation of eMAR
March - June 2011
Collect incidence data as follows
January 2007 to December 2010 pre-implementation
IRF data of July 2011 to June 2012
Collect eMAR administration data to identify delayed administration, omission of drug, reason for delayed administration, reason for omission of drug, ontime medication administration record from online medication administration record system effective from July 2011 - June 2012
Data Analysis for number of medication incidence related to delayed/omission of drug from July 2011 -June 2012 after eMAR and number of medication incidence reported during same time from IRF. Both data will compare to investigate does eMAR helps to reduce delayed administration error or not.
Result &Paper Writing