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Transcript of Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for...
![Page 1: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516e6cc550346fe558b4773/html5/thumbnails/1.jpg)
Safe IT systems?Safe Patients?
Professor Bryony Dean FranklinOctober 2012
CMSSQCMSSQCentre for Centre for MedicationMedication Safety & Service Safety & Service Quality Quality
![Page 2: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516e6cc550346fe558b4773/html5/thumbnails/2.jpg)
Why are you still studying medication errors? There
won’t be any soon, once we have electronic prescribing…
![Page 3: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516e6cc550346fe558b4773/html5/thumbnails/3.jpg)
Automation and IT in pharmacy...
![Page 4: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516e6cc550346fe558b4773/html5/thumbnails/4.jpg)
Examples
• Electronic prescribing (+/- electronic medication administration records in hospital and care home)– with various levels of decision support
• Automated dispensing– Pharmacy based (“robots”)– Ward based (“vending machines”)– Aseptic compounding robots– Automated CD storage
• Barcode verification of medication and/or patients
• “Smart” IV pumps
![Page 5: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516e6cc550346fe558b4773/html5/thumbnails/5.jpg)
A quiz
• Inpatient electronic prescribing with prescriber order entry – is it more prevalent in:
A. USA ?
B. UK ?
![Page 6: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516e6cc550346fe558b4773/html5/thumbnails/6.jpg)
UK hospital electronic prescribing
• 101 (61%) of 165 hospital trusts responded in survey of English hospitals– 70 (70%) had at least one EP system in place– 56% of sites with EP had more than one system in
place. Four sites had more than 4 systems.– 63 different systems
• Nearly half of respondents had EP systems supporting in-patient prescribing (47.5%, n=48).
• Discharge prescribing in 65.3% (n=66) of sites. • Outpatients was the least catered for (5.9%, n=6).
Ahmed, Franklin and Barber, 2012
![Page 7: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516e6cc550346fe558b4773/html5/thumbnails/7.jpg)
UK hospital electronic prescribing
• 101 (61%) of 165 hospital trusts responded in survey of English hospitals
– 70 (70%) had at least one EP system in place
– 56% of sites with EP had more than one system in place. Four sites had more than 4 systems.
– 63 different systems
• Nearly half of respondents had EP systems supporting in-patient prescribing (47.5%, n=48).
• Discharge prescribing in 65.3% (n=66) of sites.
• Outpatients was the least catered for (5.9%, n=6).
Ahmed, Franklin and Barber, 2012
![Page 8: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516e6cc550346fe558b4773/html5/thumbnails/8.jpg)
US hospital CPOE
• ASHP national survey of pharmacy practice in hospital settings 2011
• Stratified random sample of 1401 hospitals• 40.1% response rate (n=562)• 34% of hospitals had computerised prescriber
order entry• 67% using electronic medication administration
records
![Page 9: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516e6cc550346fe558b4773/html5/thumbnails/9.jpg)
US hospital CPOE
• ASHP national survey of pharmacy practice in hospital settings 2011
• Stratified random sample of 1401 hospitals• 40.1% response rate (n=562)
• 34% of hospitals had computerised prescriber order entry
• 67% using electronic medication administration records
![Page 10: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516e6cc550346fe558b4773/html5/thumbnails/10.jpg)
A quiz
• Inpatient electronic prescribing with prescriber order entry – is it more prevalent in:
A. USA ?
B. UK ?
![Page 11: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516e6cc550346fe558b4773/html5/thumbnails/11.jpg)
A quiz
• Inpatient electronic prescribing with prescriber order entry – is it more prevalent in:
A. USA ?
B. UK?
![Page 12: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516e6cc550346fe558b4773/html5/thumbnails/12.jpg)
Automation of dispensing in hospitals
• Automated dispensing systems– Pharmacy based (“robots”)– Aseptic compounding robots – Ward based (“vending
machines”)• 6 (7%) of 91 UK respondents • (cf 89% in USA)
– Automated CD storage • 2 (2%) of 91 UK respondents
McLeod, Barber and Franklin, 2012
![Page 13: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516e6cc550346fe558b4773/html5/thumbnails/13.jpg)
Aseptic compounding robot
Verifies bags using barcode Verifies vials using photo recognition
![Page 14: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516e6cc550346fe558b4773/html5/thumbnails/14.jpg)
Ward-based automated storage
Verifies product on loading, using barcode
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Automated CD storage
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Are our IT systems safe?
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Are our patients safe?
![Page 18: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516e6cc550346fe558b4773/html5/thumbnails/18.jpg)
What’s the evidence?
![Page 19: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516e6cc550346fe558b4773/html5/thumbnails/19.jpg)
International literature
• Studies of CPOE generally show benefits (17-81% reduction in errors)– But increasing realisation that new types of
error
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Smart pumps
• Used in 68% US hospitals
• Drug “libraries” to permit checking of doses and infusion rates
• Require standardisation of concentrations etc
• Bypassing of the safety software is common
• Nuckols et al: Only 4% of preventable IV ADEs would be preventable with smart pumps
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UK evaluations
• Electronic prescribing in hospitals– Most (but not all) evaluations show a modest reduction in
prescribing error
• Closed loop ward based automated dispensing system with barcode verification– More dramatic reduction in administration errors
• Dispensing robots– Reduction in “wrong content errors”
• Smart pumps?• Ward-based automated dispensing?
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Why?
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What is technology good at?
• Repetitive tasks, same every time• Follows the rules• Forcing functions
– Can’t proceed until you’ve completed all the fields
• More legible than handwriting• Reminders• Supporting formularies, protocols, standardisation
of treatment • Audit trail
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But…
• Can be inflexible
• New error types– Selection errors from menus
– Menus often present very long lists of options which prescribers not familiar with
– Assumptions - “the computer must be right”
• New work processes may be required, which can themselves increase or decrease errors– Development of workarounds
• Alert overload
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Unintended consequences
![Page 26: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516e6cc550346fe558b4773/html5/thumbnails/26.jpg)
Selection errors
• Selection of penicillamine, instead of penicillin • Menu arranged alphabetically in hospital
system– Paracetamol soluble tablets– Paracetamol suspension– Paracetamol tablets
• Many patients prescribed paracetamol soluble tablets – At risk of hypernatraemia
![Page 27: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516e6cc550346fe558b4773/html5/thumbnails/27.jpg)
Selection errors
• Selection of penicillamine, instead of penicillin • Menu arranged alphabetically in hospital
system– Paracetamol suspension– Paracetamol tablets– Paracetamol tablets soluble
![Page 28: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516e6cc550346fe558b4773/html5/thumbnails/28.jpg)
Assumptions
• Human-computer interaction causes most deaths of all IT induced fatalities– Eg a UK hospital: ~1000 cancer patients under-
dosed with radiotherapy over 9 years. Decision support software incorporated in machine, staff did not know and applied a second, manual dose reduction calculation
– McKenzie ‘Knowing machines’ 1996
– Assumption that EP system would include allergy checking, when it didn’t...
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Workarounds
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Workarounds
• Increased patient identification from 17% of doses with manual system, to 81% with barcode system
• Why only 81%?• Staff sometimes found the
wristband hard to scan, and so stuck the barcode to the patient’s table…
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Alert overload
• “If you have too many warnings from the computer then that makes you tend to override them, you become a bit more cavalier and that's a danger.” (Practice Study, PR6-GP3)
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How do we maximise error reduction and minimise new errors?
![Page 34: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.](https://reader035.fdocuments.net/reader035/viewer/2022070306/5516e6cc550346fe558b4773/html5/thumbnails/34.jpg)
1. Health warning
• Do not assume that benefits in other health systems / other countries will extrapolate to your own context
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2. Systems aren’t “plug and play”
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3. Local evaluation essential
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When do we measure the effectiveness of the system?
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When do we measure the effectiveness of the system?
With thanks to Nick Barber
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Conclusions
• Huge potential patient safety benefits• Success in achieving these is dependent on
many other contextual and organisational factors• Local evaluation is essential
– Need some form of ongoing monitoring and refining of the system. And listening to users
• Need a good relationship with suppliers• Embedding systems into everyday practice is a
long-term project
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