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Page 1: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.

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.

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.

Automation and IT in pharmacy...

Page 4: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Ward-based automated storage

Verifies product on loading, using barcode

Page 15: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.

Automated CD storage

Page 16: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.

Are our IT systems safe?

Page 17: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.

Are our patients safe?

Page 18: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.

What’s the evidence?

Page 19: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.

International literature

• Studies of CPOE generally show benefits (17-81% reduction in errors)– But increasing realisation that new types of

error

Page 20: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.

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?

Page 22: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.

Why?

Page 23: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.

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

Page 24: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.

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

Page 25: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.

Unintended consequences

Page 26: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.

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.

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.

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...

Page 29: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.

Workarounds

Page 30: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.

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…

Page 31: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.
Page 32: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.

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)

Page 33: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.

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.

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

Page 39: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.

When do we measure the effectiveness of the system?

Page 40: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.

When do we measure the effectiveness of the system?

With thanks to Nick Barber

Page 41: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.

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

Page 42: Safe IT systems? Safe Patients? Professor Bryony Dean Franklin October 2012CMSSQ Centre for Medication Safety & Service Quality.