The first report of The Institute of Medicine (IOM), the famous ‘To Err is Human’ published in 1999 revealed that around 7000 deaths occur annually from medication errors alone. In 2006, another report from the IOM pointed out that the extra medical costs for preventable adverse drug events occurring in hospitals amount to $3.5 billion a year. A study published in the Journal of Patient Safety in September 2013 found that a lower limit of 210,000 deaths occurred per year related to preventable drug events in hospitals. The solutions recommended in medical literature required the participation of pharmacists, drug manufacturers, information systems along with the communication efforts of hospital personnel. The American Academy of Orthopedic Surgeons (AAOS) puts forth certain technological solutions for physicians which will help them prevent medication errors. As per the AAOS, these solutions can considerably reduce medication errors, enhance the quality of care and patient management, increase reimbursement and reduce medical billing time. Here are the technological solutions recommended for each phase of medication delivery.
- Computerized Physician Order Entry (CPOE) – With the help of CPOE, orthopedic surgeons can order medications, tests and procedures directly into the hospital’s computer system so that missing data errors related to dosage, route and frequency of administration can be avoided. Researches have shown its annual return on investment can range from $180,000-$900,000. Improved data collection would result in accurate medical coding and increased reimbursements. Medication errors can cause lack of continuity of care during hospitalization. CPOE can enhance communication efforts in between the transfer of care. While the centralized charting functions can provide more complete and timely patient information, alert functions can highlight pertinent data (for example, allergies) and help on-call doctors in assessing and planning patient care. CPOE software is customizable so as to allow surgeons to prescribe their routine orders and make modifications as per their needs.
- Computerized Decision Support Systems (CDSS) – CDSS provides the services that would have a greater impact on surgeons’ decisions and plan of patient care such as review of orders as they are written, appropriate dosing schedules, comparison of new and existing orders, scanning for all possible drug interaction and can also give alerts to the surgeon regarding the relevant lab results. This system can provide important reminders and alerts and improve the clinical performance in relation to prescribing practices. It can also recommend alternative medications that are less expensive and thereby reduce patient care costs. CDSS has the ability to detect and prevent duplications associated with medications, testing and imaging.
- Pharmacist-assisted Rounds – Utilization of staff pharmacists during medication decisions is one of the least expensive as well as easily accessible tools. Being familiar with the institution’s formulary, pharmacists can assist doctors in choosing appropriate and efficient medications, especially in case of challenging situations such as patients on multiple medications, organ failure and other conditions. They can also assist physicians in practicing evidence-based medicine. Compared to non-formulary medications, formulary medications have a lower cost and a higher reimbursement rate. Easy availability of formulary medications in adjacent pharmacies increases the possibility of patient compliance with post-operative medications.
- Standardized Order Sets – If CPOE and CDSS are not available, it is required to use standardized order sets and clinical pathways for frequently performed procedures and admissions. This will reduce the length of hospital stay and improve the quality of care. Orthopedic surgeons are required to customize their order sets for clinical preferences and utilize them for minimizing handwriting errors and increasing standardization of care. Order sets need to be reviewed with pharmacy personnel in order to reduce the use of expired or inappropriate medications and ensure compliance with formulary requirements.
CPOE and standardized order sets can help avoid handwriting errors that may result in undesirable consequences for the patient. Abbreviations of drug names should be avoided in prescriptions. Instead of using abbreviations, dosage units should be spelled out. Use a zero to the left of a dose less than 1 and do not use a terminal zero to the right of the decimal point in order to minimize dosing errors.
The electronic order transcription accomplished with CPOE can increase the speed and accuracy of transcription so that there will be less medication errors. In the absence of CPOE, reduced handwritten orders and use of standardized order sets would improve the transcription process.
- Verbal Order Verification Avoid verbal orders as far as possible and implement specific procedures to ensure clarity among healthcare personnel. Standing order sets can help avoid many verbal orders. In case a verbal order is given, a ‘read-back and verify’ protocol should be implemented to ensure proper interpretation of that order.
- Automated Dispensing – This technology can prevent human factors errors including “look alike” and “sound alike” drugs and ensure the correct dosage. In 2007, a national forum was convened by the Institute for Safe Medication Practices, along with invited stakeholders for developing updated safe-use guidelines for automated dispensing cabinets.
- Bar Coding – The U.S. Food and Drug Administration (FDA) mandated in 2006 that hospitals should use bar codes for medications. This rule was finalized in 2004 and hospitals were given two years to comply with the rule which required stepping into the use of bar code technologies in human drug products and biologic products. Bar code system can automatically identify the national drug code (NDC) for specific manufactured products which result in better scheduling of medication, less missed doses, more efficient drug monitoring, improved medical records, better communication among healthcare staff and even cost efficiencies. The right patient, right drug and the right dosage can be identified with bar coding.
- Unit Dose Packaging – Package pharmaceuticals in unit dose applications will improve the administration of the proper drug and dose to the right patient when used together with bar code readers and computer systems. To comply with federal regulations, pharmaceutical manufacturers will be instituting this kind of packaging for the next few years.
There should be high-risk drug protocols/policies in place as national patient safety organizations recommend monitoring safety practices while using high-alert medications. Remove concentrated electrolytes including but not limited to sodium chloride, potassium chloride, and potassium phosphate more than 0.9% from patient care units. Hospitals are required to recommend pharmacies to reduce the number, concentrations and volume of high-risk medications (warfarin, theophylline, narcotics, muscle relaxants, magnesium, lidocaine, insulin, immunoglobin, heparin, dextrose injections, chemotherapeutic agents and adrenergic agents) in formulary.
Administering and Monitoring
The administration phase is a prominent source of medication errors and the use of automated drug dispensing, unit dose packaging and bar coding can eliminate most of these errors. A computerized order entry system alone or in concert with a decision support system can identify potential medication errors and offer solutions for them. Additionally, it can record data related to errors and near misses for further uses. If such a system is not available routine patient chart audits can deter flawed practices. Medication errors can also be reduced by educating patients.
- Medication Administration Record (MAR)MARs record the time, date and route of administration of medications ordered along with the identity of the healthcare provider who prescribes the medications. Incorporation of MAR into a computerized system can generate typed orders and administration information instead of handwritten orders, and this which would reduce the number of medication errors. Computerized MAR can also record the data by the time the process occur so that there will be no confusion over the details of administration such as whether a dose was administered, when was it administered and so on. It is possible to program MAR in such a way that it require a co-signer for high-risk medications so as to implement a double-check measure.
Medical literature suggest that environmental factors including fatigue, poor lighting, interruptions, noise, and an excessive workload may cause medication errors. It is the responsibility of hospitals and ambulatory surgical centers to evaluate and monitor these factors and ensure the distractions caused by them are kept to a minimum. If an error occurs, hospital administration, quality assurance, risk management, and physicians should investigate the root cause of the error and rectify it as soon as possible in case it is problematic.
Medication reconciliation aims at optimizing drug therapy by accurately and completely reconciling medication while minimizing adverse drug events across the continuum of care. There should be a medication list that keeps track of what the patient is currently taking and what medications are subsequently prescribed. The medications may include prescriptions, over-the-counter drugs, vitamins, herbal supplements, and any product that is designated as a drug by the FDA. The Joint Commission insists that home medication (medication taken before patient’s entry to the hospital) list should be obtained within 24 hours of admission as part of the initial assessment. With the help of electronic records, medication can be tracked easily and reconciliation can be more effective.
The Role of Electronic Medical Records (EMRs)
As per AAOS, the implementation of EMRs can significantly reduce the medication adverse events, improve patient health and provide cost savings to healthcare providers. Orthopedic surgeons can access patient records and history very easily. Though the cost benefits won’t be that much evident during the adoption period, gradual increase can be seen in due course of time. EMRs are beneficial only if the information entered into the system is complete and accurate.
However, the EMR drop-down boxes and templates are not much effective in capturing meaningful conversation. It can’t offer 100% accuracy even when used with speech recognition software as the software doesn’t recognize grammatical mistakes and punctuation errors. Moreover, it does not have the capability to expand the acronyms. Though copying information from one file to another in an EMR system may save the time of surgeons, irrelevant or wrong information may be entered by mistake while doing this routinely (copy and paste errors). These kinds of challenges can be resolved by combining EMR with transcription and seeking help from trained medical transcriptionists. With the support of a professional medical billing and coding company that offers EHR/EMR feeds, healthcare specialists can streamline their revenue cycle and achieve better cost benefits.