Cincinnati Children's Hospital Medical Center is in the vanguard of medication management safety in the United States, thanks to an initiative led by one its pediatricians, who has also been its director of technology and patient safety. And, says that physician, none of the hospital's advances could have been made without computer-based provider order entry (CPOE).
“We care for a lot of very sick children, use a lot of technology, and throw a lot of plans and medications and treatments at them, so it's a potentially highly toxic environment,” says Brian Jacobs, M.D., the leader of Cincinnati Children's Hospital's medication safety initiative. (In August, Jacobs accepted an offer from Children's National Medical Center in Washington, D.C., to move there and spearhead a similar initiative).
“The risks to medication safety are quite high in pediatric hospitals compared to in typical adult floor beds,” he adds.
Since rolling out its CPOE system in 2002, Jacobs reports, the 423-bed hospital has documented numerous medication safety gains. Its intensive-care unit (ICU) mortality rate has dropped steadily from 4.6 percent prior to CPOE rollout, to 3.1 percent last year. At the same time, 92 percent of orders are now entered directly by physicians or nurse practitioner-prescribers into the system (versus 22 percent of medication orders historically given verbally). And medication administration turnaround time to the bedside has dropped from two hours to one, improving antibiotic therapy to patients.
Most exciting of all, though, is the proactive, automated error-detection program that Jacobs established, and which relies on the CPOE system for its electronic triggers.
“We've found 10–12-fold underreporting of errors,” Jacobs notes. “Using an automated detection system is a way to truly understand your errors, and even more importantly, to proactively redesign care processes to proactively avert events.”
The detection system automatically trawls the electronic medication administration record (eMAR) for certain events, searching for administration of opiate antidotes, for example. In that example, 70 percent of opiate antidote dispensations have been traced to some kind of triggering medication error. Given such incidents, the system automatically alerts clinical risk managers to investigate and find out what occurred.
“So this is a tremendous way for an EMR to automatically detect errors taking place in your hospital. This allows you to look at an overall picture and design strategies. If I have 10 morphine errors a month but only one is reported, I'm going to make changes.” Most importantly, a hospital-wide medication safety committee is constantly finding ways to rework clinical processes for greater medication safety, based on the data the error-detection program uncovers, he says.
Next month: Advancing patient safety at the bedside.
Nationwide push for safety
Industry experts say that, thanks to an intense public and policy focus on medication safety, improvements in technology, and most of all, the implementation of electronic medical records (EMRs), eMAR and CPOE systems in hospitals, medication safety improvement is finally happening.
“Speaking as a pharmacist, I'll say that pharmacy has for years been making headway in getting involved in more clinical aspects of the process; so the pharmacy's having a major impact in improving meds use,” says David Troiano, a Houston-based senior manager at Long Beach, Calif.-based First Consulting Group, who advises hospital organizations on medication management- and CPOE-related issues. “I think organizations are doing well in raising awareness of medical errors and medication errors specifically; I don't think they're having as much success with reporting errors.”
Still, he says, somewhere between 25 and 50 percent of hospitals are moving forward at varying speeds with CPOE, bar-coded medication administration, and “smart-pump” implementations. And, he adds, EMR, eMAR and CPOE capabilities will be absolutely necessary in order to make significant medication safety gains going forward.
Troiano's colleague, research director Fran Turisco, who is in FCG's Boston office, has been working with colleague Jane Metzger on a project helping a national children's hospital association analyze the gaps in interfaces between medication-related information systems (EMR, eMAR, CPOE), and where processes tend to break down.
“One of the toughest things to manage,” Turisco says, “is the transition between what the physician orders and what actually gets dispensed. The way a physician orders a medication is going to be different from the way a pharmacy sees it and dispenses it; the data is presented differently. The smarter pharmacy systems provide a display to show generic equivalents in different doses.”
Computer-based Provider Order Entry
CPOE is the portion of a clinical information system that enables a patient's care provider to enter an order for a medication, clinical laboratory or radiology test, or procedure directly into the computer. The system then transmits the order to the appropriate department, or individuals, so it can be carried out. The most advanced implementations of such systems also provide real-time clinical decision support such as dosage and alternative medication suggestions, duplicate therapy warnings, and drug-drug and drug-allergy interaction checking (Osheroff, 2005).
The Leapfrog Group has a narrower definition of CPOE. A hospital that has made Leapfrog's CPOE leap has 75 percent of all medication orders entered by physicians using a computer system that provides some level of clinical alerts. Leapfrog results are self-reported by hospitals via an unaudited survey process.
It might be a simple example, but such discrepancies very often lead to meds administration errors, she points out.
And, even as hospitals move down the path of trying to improve medication safety, Troiano says, “What some hospitals are doing wrong — and you see it in some of these problematic implementations — is that they're not thinking through all the processes from beginning to end. Fundamentally, you have a medication-use process, not three separate nursing, physician and pharmacy processes.”
Getting all three clinical disciplines to work together is essential to success, he notes. It's also something that sounds very simple in theory, but is difficult in practice.
As challenging as improving medication safety is, numerous hospital organizations around the country are doing it. Among them:
Hospital of Saint Raphael
At the Hospital of Saint Raphael in New Haven, Conn., Janet Kozakiewicz, Pharm.D, director of pharmacy services, reports that the hospital, which rolled out its eMAR and CPOE in 2002, has made significant strides in a number of areas.
For example, Kozakiewicz and her colleagues have been carefully analyzing 16 issues around variances in CPOE-facilitated medication orders, to determine where there are problems. They are fixing problems in order-set content and standardization, dispensing and delivery, and meds administration.
In addition to making progress in reducing variation, Kozakiewicz notes that the amount of time from meds order to meds administration at bedside has gone from 120 minutes to 30 because of CPOE implementation, an efficiency gain that is in effect also a patient-care quality advance.
What's more, whereas prior to CPOE implementation clinicians were able to convert 20 percent of patients from intravenous to oral therapy, that figure is now 60 percent, which contributes to decreased lengths of stay.
The Hospital of Saint Raphael is using medication management and dispensing systems from Dublin, Ohio-based Cardinal Health.
Sacred Heart Medical Center
At Sacred Heart Medical Center in Eugene, Ore., a 432-bed hospital that is part of five-hospital, six-medical group PeaceHealth system in the Pacific Northwest, Paul Roche, Pharm.D., the hospital's pharmacy clinical manager, reports that the hospital documents 10,000 medication alerts annually thanks to the integration of a pharmacy clinical decision-support system with the facility's eMAR.
Sacred Heart is using a CDS solution from the Salt Lake City-based TheraDoc Inc., and its eMAR system is from Burlington, Vt.-based IDX Systems Corporation, now a part of Barrington, Ill.-based GE Healthcare.
Roche says, “Though we had thought we were doing a good job on patient electrolyte abnormalities” before implementing the pharmacy CDS solution, “We're catching those abnormalities a lot earlier now,” averting cardiac arrhythmias, low-sodium-based patient confusion, and other hazards.
Inevitably, say many of those interviewed, the development of alert-based systems, clinical decision-support systems and CPOE leads to a realization about the extent of medication errors in hospitals, and the degree to which so many errors and near misses go unreported and even undetected altogether.
“Prior to going live hospital-wide, we went two weeks with the TheraDoc system on, and then turned it off again for two weeks before doing the sustained go-live,” Sacred Heart's Roche says. “We had taken pride in our work” in the medication management arena, “but since go-live, we've found we had been missing things because of a lack of information. Our system pushes information to us in a far more accessible, actionable way now.”
And it's the deeper process analysis and process redesign that will reap the greatest rewards, emphasizes Paul Johnston, a senior consultant at Healthia Consulting, Minneapolis, Minn.
“The key thing in medication management is to actually look at and diagram workflows,” he says. “You have a choice when it comes to automation: You can either replicate your old processes in a computerized system, or you can optimize your processes and your workflow as much as possible, look at efficiencies, and try to streamline ordering as much as possible, and put in decision-support tools to help clinicians as much as possible.”
Mark Hagland is a contributing writer based in Chicago.