Medication safety through information technology: a focus on medication prescribing and administration

Elektronisch voorschrijven voorwaarde voor medicatieveiligheid Ziekenhuizen die IT-toepassingen als beslissingsondersteuning en barcodering gebruiken bij het voorschrijven en toedienen van medicijnen, werken efficiënter én maken minder fouten. Dit concludeert ziekenhuisapotheker Pieter Helmons in zijn proefschrift. Zijn onderzoek kan helpen bij het selecteren en configureren van deze nieuwe technologieën en biedt methodes om de effecten op medicatieveiligheid te meten. Op 1 januari 2014 is de KNMG-richtlijn ‘Elektronisch voorschrijven’ van kracht geworden. Hierdoor mogen artsen alleen nog elektronisch medicatie voorschrijven. Bovendien is het verplicht dat deze elektronische voorschrijfsystemen de arts op het moment van voorschrijven attenderen op mogelijke problemen. Bij dit laatste is bijvoorbeeld te denken aan ongewenste combinaties van medicijnen of de melding dat een patiënt bijkomende ziekten heeft waarvoor een medicijn wordt afgeraden. De huidige elektronische voorschrijfsystemen en apotheeksystemen zorgen echter voor veel irrelevante meldingen, omdat deze systemen niet alle gegevens gebruiken die noodzakelijk zijn om een relevante melding voor de arts of apotheker te genereren. Kortom, er worden wel veel gegevens elektronisch vastgelegd, maar deze worden niet omgezet in bruikbare informatie voor de voorschrijver. Helmons deed zijn promotieonderzoek in samenwerking met het UMCG in het Catharina Ziekenhuis Eindhoven, het Ziekenhuis St Jansdal in Harderwijk en in het University of California San Diego Medical Center (UCSD) in San Diego (VS). Hij richtte zich op de effecten van IT-toepassingen op de kwaliteit van het voorschrijven en toedienen van medicatie in het ziekenhuis. Uit zijn onderzoek blijkt dat systemen die laboratorium-, demografische- en medicatiegegevens van de patiënt aan elkaar koppelen via klinische beslisregels, de zogeheten beslissingsondersteunende systemen, essentieel zijn om de juiste informatie aan de behandelaar te presenteren. Dit maakt een nieuwe en efficiëntere manier van medicatiebewaking mogelijk. De juiste toediening van medicatie wordt met name in Amerikaanse ziekenhuizen ondersteund door het scannen van barcodes op medicatie. Helmons ging na wat het effect hiervan was op medicatie-toedienfouten. Hij toonde een grote reductie hiervan aan op de verpleegafdeling, maar ook dat er geen effect op de Intensive Care-afdeling was. Verder bleek bar-codering het aantal verkeerd gevulde medicijnen in een geneesmiddeluitgifte apparaat met bijna 80% te verminderen. Helmons concludeert dat bar-codering niet een one-size-fits-all oplossing is voor medicatie toedienfouten. Helmons ziet elektronisch voorschrijven van medicatie als een essentiële voorwaarde om technologieën te implementeren die als doel hebben de medicatieveiligheid te verhogen tijdens de meest kritische stappen van het medicatiegebruik in ziekenhuizen, namelijk het voorschrijven en toedienen van medicatie. The delivery of hospital care is changing: the aging population results in more patients being admitted to hospitals, but are discharged sooner. As a result, hospitals invest in information technology to assure safe and effective treatment and facilitate rapid patient turnover. In this thesis we describe the consequences of clinical decision support systems (CDSS) and bar-code technology on the most error prone steps of hospital medication use: medication prescribing and administering. We focus in our research on quality (e.g. quality of antimicrobial dosing, medication administration errors and automated dispensing cabinet refill errors) and efficiency aspects (e.g. cost of excess antimicrobial dosing, return on investment of CDSS assisted drug-drug interaction checking and workflow optimization). We describe and research the shortcomings of our current information systems and the barriers to adoption of effective clinical decision support. As an example of our work, we used a CDSS to augment conventional drug-drug interaction checking. Adding a CDSS decreased the number of alerts by 55%, resulting in a decreased time investment by the pharmacist. We also investigated bar-coded medication administration (BCMA) technology to improve the safety and quality of medication distribution and administration. BCMA implementation decreased medication administration errors on general medicine floors, but not on the Intensive Care Unit. To summarize, increased availability of electronic data in hospitals opens many doors for technologies aimed at increasing medication safety in those areas that are most critical; medication prescribing and administering. This thesis can help in selecting and configuring these technologies and measuring its effects.

Formulary compliance and pharmacy labor costs associated with systematic formulary management strategy

Purpose. The impact of a comprehensive hospital formulary management system on formulary compliance and pharmacy labor costs was evaluated. Methods. The formulary management system consisted of monitoring nonformulary medication use, reviewing formulary medication use annually, and providing periodic feedback. Workflow scenarios for nonformulary medication requests were identified. Pharmacy personnel were interviewed to obtain the probability of occurrence of each scenario and the time involved. Labor costs were determined by multiplying the average total minutes spent on each activity by the corresponding average salaries per minute. Formulary compliance was compared before the implementation of the formulary management system (January to June 2008) with six consecutive six-month periods after implementation. Results. Nonformulary medication use decreased from 17.8 to 5.9 nonformulary medication initiations per 100 admissions over a three-year period (p <0.001). Time and labor costs associated with managing nonformulary medication requests varied from 4 to 69 minutes and from $3.68 to$27.28, respectively, depending on the scenario used. Automatically converting to a formulary alternative was the least labor-intensive option ($4.40 per request), followed by changing to a formulary alternative after consulting the prescriber ($9.92). Conclusion. A comprehensive formulary management system resulted in increased compliance to a formulary that matched the needs of the institution and minimized the number of nonformulary medication requests. Expanding pharmacists' therapeutic interchange authorities was the least labor-intensive way of managing nonformulary medication requests, and adding the most frequently used nonformulary medications to the formulary was the second least costly option

Decision support at the point of prescribing to increase formulary adherence

Purpose. Study results demonstrating the effectiveness of order-entry clinical decision support (CDS) alerts as a tool for enforcing therapeutic interchange are presented. Methods. A retrospective observational study was conducted at an academic medical center to evaluate formulary nonadherence before and after implementation of a fully electronic medical record with computerized prescriber order-entry (CPOE) technology configured to display therapeutic interchange alerts immediately on entry of orders for nonformulary agents. Formulary nonadherence (defined as the proportion of pharmacist-verified nonformulary orders to total verified orders) within eight medication classes was assessed during a six-month baseline period and two consecutive six-month periods after implementation. Results. In the 12 months after implementation of the therapeutic interchange alerts, the overall rate of formulary nonadherence decreased by 65%, from 3.5% at baseline to 1.2% during the second 6-month postintervention period (p <0.001). The total number of verified nonformulary orders decreased from 300 at baseline to 102 during the second postintervention period. The largest decreases in formulary nonadherence were observed in the intranasal steroid drug class (the rate of nonadherent orders declined by a total of 12 percentage points) and the nonbarbiturate sedatives and hypnotics class (a 5-point decline), with significant 6- and 12-month declines also documented in four of the remaining six drug classes. Conclusion. The incorporation of hard-stop CDS alerts into the CPOE system improved the overall rate of prescriber adherence to institutional therapeutic interchange protocols

Drug-drug interaction checking assisted by clinical decision support:a return on investment analysis

Background Drug-drug interactions (DDIs) are very prevalent in hospitalized patients. Objectives To determine the number of DDI alerts, time saved, and time invested after suppressing clinically irrelevant alerts and adding clinical-decision support to relevant alerts. Materials and methods The most frequently occurring DDIs were evaluated for clinical relevance by a multidisciplinary expert panel. Pharmacist evaluation of relevant DDIs was facilitated using computerized decision support systems (CDSS). During Phase 1, only CDSS-assisted DDI checking was implemented. During Phase 2, CDSS-assisted DDI checking remained in place, and clinically irrelevant DDIs were suppressed. In each phase, the number of alerts and duration of pharmacist DDI checking were compared to conventional DDI checking. In addition, the time invested to implement and configure the CDSS was compared to the time saved using CDSS-assisted DDI checking. Results CDSS-assisted DDI checking resulted in a daily decrease of DDI checking alerts from 65 to 47 alerts in Phase 1 (P=.03) and from 73 to 33 alerts in Phase 2 (P=.003). DDI checking duration decreased from 15 to 11 minutes (P=.044) and from 15 1/2 to 8 1/2 minutes (P=.001) in Phases 1 and 2, respectively. Almost 298 of the 392 hours required for implementation were invested by pharmacists. An annual timesaving of 30 hours yielded a return on investment of 9.8 years. Conclusion CDSS-assisted DDI checking resulted in a 55% reduction of the number of alerts and a 45% reduction in time spent on DDI checking, yielding a return on investment of almost 10 years. Our approach can be used to refine other drug safety checking modules, increasing the efficiency of checking for drug safety without the need to add more staff pharmacists

Doing the right things and doing things right:inpatient drug surveillance assisted by clinical decision support

Increased budget constraints and a continuous focus on improved quality require an efficient inpatient drug surveillance process. We describe a hospital-wide drug surveillance strategy consisting of a multidisciplinary evaluation of drug surveillance activities and using clinical decision support to augment drug surveillance practices. Key characteristics of the decision support system are the integration of the Dutch national knowledge base (G-Standard), the ability to monitor the effects of drug therapy over time and prevent irrelevant alerting by adding essential patient data to the conventional medication safety checking algorithm. Integration of existing national medication safety knowledge bases into decision support systems assures the availability of up-to-date information, minimises maintenance and prevents irrelevant alerts. Developing decision algorithms based on the desired intervention decreases the burden of validation and maintenance, as duplication of multiple similar decision algorithms is prevented