Written by Chelsea Blackley
The process of prescribing, administering and the overall management of patients’ medications can be complex and there are plenty of opportunities within this process in where errors can be made (Houghton & Parsotam, 2011). Drug errors have the potential to severely jeopardise a patient’s wellbeing leading to increased hospital stays, loss of trust in a therapeutic relationship and the potential for long term harm or even death (Ammenworth, Schnell-Inderst, Machan & Siebert, 2008; Davis, Lay Yee, Briant, Schug, Scott, Johnson &Bingley, 2001). The general public would like to believe that instances of drug errors are extremely rare in our New Zealand hospitals however there are a lot more common than the public would assume and medication errors continue to be a recognised problem in the New Zealand health and disability sector (Davis et al., 2001). This literature review looks foremost at the issues around drug errors as well as the benefits of Electronic Prescribing and Administration programs (ePAs) and the ways in which ePAs reduce drug errors.
Due to the severe impact that drug errors can have on patients, I believe that any means of decreasing the prevalence of these errors should be explored. Being a student nurse and having placements within a New Zealand DHB, I have had the opportunity to work with both handwritten paper charting of medication, as well as the new MEDCHART Electronic Prescribing and Administration technology. I believe that the Electronic Prescribing and Administration system (ePA) is superior to the paper charting as I found it easier to use from a nursing student perspective for multiple reasons such as the ability to easily read doctors prescriptions and ease of access to further information about the drugs prescribed. However, I wanted to explore this first impression by undertaking a literature review and validating exactly how ePAs reduce drug errors.
I undertook a search of peer reviewed articles relating to the question ‘In an inpatient setting, How does the Implementation of Electronic Prescribing and Administration Technology Result in Reduced Drug Errors?’. The PECOT method was used to clarify this question in order to focus the search for valid literature. PECOT stands for the patient population of interest, the intervention, a comparison, the outcome of interest and time (Schneider, Whitehead, LoBiondo-Wood & Haber, 2013). The population that this review focuses on is those within an inpatient setting. This excludes any use of paper charts or ePAs in outpatient or community settings. This should also exclude any use of uncharted medication. The exposure or intervention that this literature review is focusing on is the introduction of Electronic Prescribing and Administration systems (ePAs) and this will be compared to the use of handwritten, paper charting. The outcome being investigated is whether this exposure decreases the amount of drug errors in this setting. Through the process of developing this review, a drug error was defined as being an error in the medication process: ordering, transcription, dispensing and administration and discharge prescriptions that has the potential to result in patient harm (Lisby, Nielson, & Mainz, 2005). The time aspect of the PECOT model did not apply to this review. I originally based this search on whether ePAs did or did not reduce drug errors but soon found that the concept of how these drug errors were reduced was more interesting and substantial than a yes or no answer. I first searched for articles related to ePAs in general. I found that electronic prescribing and administration systems were most likely to be based in tertiary healthcare settings and an easily observed indicator of their success is the reduction in the number of drug errors on wards where ePAs have been implemented. Although there were not a large array of articles overall, I decided to continue using this topic and took my research further by requesting a meeting with a member of the DHB MEDCHART Project Implementation Team to give me some guidance in searching for additional relevant articles. I ensured that this information was peer reviewed and validated to avoid bias.
Articles critiqued in this review included both international and New Zealand studies that identified the prevalence of drug errors and their potential to result in a mirage of issues in our own hospitals. One study stated that drug errors are internationally found to be the leading cause of patient injury in the hospital setting. They are responsible for significant patient morbidity and mortality, as well as being a high contributor to the occupancy, and therefore lack of, available beds in hospitals (Kunac & Reith, 2008). A report written for the Health Quality and Safety Commission and the National Health Information and Technology Board that was based on the implementation of MedChart in the local hospital and estimated that drug errors cost our health system $590 million a year (Houghton & Parsotam, 2011). Another New Zealand study in a Hawkes Bay hospital states that there is abundant evidence that medication is associated with an undesirable number of errors and adverse events (Gommans, Mcintosh, Bee, & Allan, 2008). A Denmark study looking at errors in the medication process found that they are one of the main causes for adverse events in hospitals leading to disability and death in up to 6.5% of patients (Lisby, Nielson & Mainz, 2005). This article also clearly identified the error types in every stage of prescribing and administration. Some errors identified included omission of a drug name or drug formulation, the wrong route or wrong dose being prescribed, unidentified or incorrect dosing regimen, missing dates, discrepancy in drug name or formulation, unordered drug or formulation, omission of doses and lack of identity control (Lisby et al., 2005).
Electronic Prescribing and Administration can avoid many issues that arise from the human error factor of paper charting. The first, and possibly most obvious issue explored in literature is the legibility of prescriptions as paper charting relies on staff deciphering the handwriting of the prescriber (Ammenworth et al., 2008). There is also a risk of important information being omitted on the paper chart. These factors were identified by a number of articles which stated that this omission of information not only lead to errors in itself, but could also result in unnecessary time spent chasing up medication and causing delays in administering medication (Westbrook, Ling, Georgiou, Paoloni & Cullen, 2013), (Tolley, 2011). ePAs address these issues by keeping prescriptions on easily read and accessible electronic devices (usually a laptop) therefore entirely eliminating illegibility issues (Houghton & Parsotam, 2011). Any gaps in information or unclear prescriptions are automatically flagged at the time of prescribing and the prescriber can address them immediately (Tolley, 2011).
It was evident in many of the journal articles reviewed that the majority of medication errors originate from the ordering/prescription stage. This stage is usually the responsibility of doctors (Houghton & Parsotam, 2011). The New Zealand article in a Hawkes Bay hospital also highlighted the fact that the quality of prescribing by junior medical staff, whom are often the ones writing the prescriptions, can be insufficient. They have limited training and experience in prescribing (Gommans Mcintosh, Bee & Allan, 2008). ePAs minimise the risk of errors by inexperienced prescribers or any other prescribers by having automatic drug dosing capabilities, alerting the prescriber of potential incompatibilities between medications and highlighting individual patient allergies among many other things (Ammenworth, 2008; Houghton & Parsotam, 2011).
Errors in other stages of prescription and administration, often under a nurses responsibility include omitting doses or giving extra doses, administering the wrong dose, administering drugs at the wrong time, using the wrong route or at an incorrect rate (Doran, 2003). This relates to the ‘Five Rights’ for nursing; Right patient, Right drug, Right dose, Right route and Right time (Crisp & Taylor, 2009). Some ePA systems include a barcode system as stated in a range of articles. Patient records are bar-coded as well as the identification bands on patients’ wrists. The barcode on the record can be cross checked with the barcode on the patient’s wrist at the bedside (Tolley, 2011). This ensures that the ‘right patient’ is identified and the ‘right drug’ is being administered. Any ‘right dose’ and ‘right route’ issues should be rectified at the time of prescription and will be clear for the administrator to see (Tolley, 2011). A report on the introduction of an ePA system in Dunedin hospital explains how the ePA system ensures that medications are given at the right time. The ePA prompts staff when medicines are due and also provides an overdue alert, both of which reduce drug administration omissions. If there is a reason why a drug is not given , the nurse will have to mark it as ‘withheld’ or ‘missed’ and clearly state a reason (Houghton & Parsotam, 2011).
It is clear from the evidence found, that Electronic Prescribing and administration technologies are a massive advantage in hospital settings by reducing the occurrence of drug errors. Actual figures representing the decrease in drug errors after electronic Prescribing and Administration programs are implemented are easily found. In the article ‘An overview of e-prescibing in secondary care’ it is stated that prescription errors were seven times less likely with an ePA system than when prescriptions were hand written (Tolley, 2011). In a report analysing the implementation of ePAs in two hospitals, the error rate in both hospitals dropped significantly by 90.2% and 93.6% while control wards experienced no significant change. When the error reductions in hospital A are broken down, duplicate medication errors were decreased from 0.37 to 0.23, wrong dose/volume errors from 0.43 to 0.25, wrong strength errors from 0.27 to 0.01 and wrong route errors from 0.11 to 0.01 per admission. In hospital B, wrong strength errors were decreased from 0.06 to 0.01 and drug not prescribed errors from 0.16 to 0.08 per admission (Westbrook et al., 2013). Another study by Donyai, O’Grady, Jacklin, Barber and Franklin (2007). found that 2.0% of prescriptions had errors post-implementation compared to 3.8% before implementation of ePA systems The systmatic review undertaken by Ammenworth et al. (2008) had possibly the most convincing statistics with twenty three out of twenty five hospitals reviewed, showing a reduction of drug errors between 13% and 99% after the implementation of electronic systems.
As convincing as these statistics from the literature reviewed appear, few systems are without faults and difficulties. There is a potential of new risks to patient care during the process of introduction of electronic Prescribing and Administrating technologies as healthcare
professionals are unsure of the processes involved. Research suggests that new error types may arise from the use of ePAs. For example, the incorrect dose and frequency or inappropriate use of a default dose can be selected (Donyai et al., 2007). There is also the issue of alert fatigue. Doctors or nurses may start to ignore important and serious alerts as they become accustomed to minor alerts frequently occurring on the systems (Westbrook et al., 2012). Other issues include excessive reliance on electronically held data, isruptions in the established workflow of wards and omission errors as healthcare professionals simply ‘give up’ when they don’t understand how to use a new system (Houghton & Parsotam, 2011). The frequency of these types of errors and issues is going to be largely dependent on the level of support given when programs are implemented. Houghton and Parsotam identify that on-going training and support is essential by most users. It was also suggested that ‘re-fresher’ sessions be held to reiterate instructions and to educate on further developments and changes (Houghton & Parsotam, 2011). Other issues that need sufficient pre-planning include the space that extra computers take up including storage and power outlet requirements, the need for extensive wifi coverage capabilities, and the need for extra passwords etcetera (Houghton & Parsotam, 2011). These things must be managed to avoid disruptions in workflow. Despite these possible hurdles in introducing ePA systems, the benefits of ePAs, particularly their role in the reduction of drug errors,
greatly out way the risks of implementation.
In summary, this literature review has shown overwhelming evidence in support of electronic Prescription and Administration technologies and the ways in which drug errors are reduced. A drug error has the potential to do harm to others and any system that can reduce this risk should be seen as beneficent or non-maleficent (Crisp and Taylor, 2009). ePAs have huge potential in the inpatient environment and their benefits target the most common drug errors. These include the omission of a drug name or drug formulation, the wrong route or wrong dose being prescribed, unidentified or incorrect dosing regimen, missing dates, discrepancy in drug name or formulation, unordered drug or formulation, omission of doses and lack of identity control. This literature review has also identified the areas in which ePAs may lead to new errors and the practises that need to be put in place to avoid these, the most relevant advice being that a strong Information Technolgy and Clinical Support and Education team need to be fully involved and readily available. With proper and careful implementation, electronic Prescribing and Administration technologies certainly have a valuable role in inpatient settings and I believe that they have the potential to one day replace paper charting in all hospitals.
Ammenwerth, E., Schnell-Inderst, P., Machan, C., & Siebert, U. (2008). The effect of electronic prescribing on medication errors and adverse drug events: A systematic review. Journal of Am Med Inform Assoc,15(5):585-600.
Crisp, C., & Taylor, C. (2009). Potter and Perry's fundamentals of nursing (3rd ed.). Chatswood, Australia: Elsevier.
Davis, P., Lay Yee, R., Briant, R. S, Schug, A., Scott, S., Johnson, & Bingley. W. (2001). Adverse Events in New Zealand Public Hospitals: Principal findings from a National Survey. Ministry of Health. Wellington, New Zealand.
Donyai, P., O’Grady, K., Jacklin, A., Barber, N., & Franklin, B. D. (2007). The effect of electronic prescribing on the quality of prescribing. British Journal of Clinical Pharmacology, 65(2), 230–237.
Doran, D. M. (2003). Nursing- Sensitive Outcomes State of the Science. London: Jones and Bartlett Publishers, Inc.
Gommans, J., Mcintosh, P., Bee, S., & Allan, W. (2008). Improving the Quality of written prescriptions in a general hospital: the influence of 10 years of serial audits and targeted interventions. Internal Medicine Journal, 38: 243–248.
Houghton, E., & Parsotam, N. (2011). Evaluation of the Electronic Prescribing and Administration System in Dunedin Hospital. Health Quality and Safety Commision New Zealand: 1–65.
Kunac, D., L., & Reith, D. M. (2008). Preventable medication - related events in hospitalised children in New Zealand. The New Zealand Medical Journal, 121(1272).
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Lisby, M., Nielson, L., Peter, & Mainz, J. (2005). Errors in the medication process: Frequency , type, and potential. International Journal for Quality in Health Care, 17, 15–22.
Schneider, Z., Whitehead., D., LoBiondo-Wood, G., & Haber, J. (2013). Nursing and midwifery research methods and appraisal for evidence – based practice (4th ed.). Sydney, NSW, Australia: Mosby.
Tolley, R. (2011). An overview of e-prescibing in secondary care. Nursing Standard, 26(22), 35-38.
Westbrook, J. I., Ling, Li., Georgiou, A., Paoloni, R., & Cullen, P. (2013). Impact of an electronic medication management system on hospital doctors’ and nurses’ work: a controlled pre–post, time and motion study. Journal of Am Med inform Assoc.0:1–9. doi: 10.1136/amiajnl2012-001414
Westbrook, J. I., Reckmann, M., Li, L., Runciman, W.B., Burke, R., Lo, C., Baysari, M. T., Braithwaite, J., & Day, R. O. (2012). Effects of Two Commercial ElectronicPrescribingSystems on Prescribing Error Rates in Hospital In-Patients: A Before and After Study. PLoS Medicine, 9(1). doi:10.