Impact of a Computerized Medication Safety System Interface on Medication Errors Willa Fields, DNSc,

1
Impact of a Computerized Medication Safety
System Interface on Medication ErrorsWilla
Fields, DNSc, RNSan Diego State UniversitySharp
HealthCareRita Snyder, PhD, RNUniversity of
NebraskaCollege of NursingApril 23,
2008Funding Source USA Agency for Healthcare
Research and Quality R01 HS013131
2

• Purpose
• Assess the impact of a computerized interface
  between a pharmacy system and nursing medication
  administration record on medication safety events
• Goal
• Eliminate medication order inconsistencies

3
Sharp HealthCareSan Diego California

• Not-for-Profit, integrated, regional, health care
  delivery system
• 4 Acute Care Hospitals
• 3 Specialty Care Hospitals
• 3 Medical Groups
• Full spectrum of other facilities and services
• 2007 Malcolm Baldrige National Quality Award
• Study Hospitals Magnet Hospitals from the
  American Nurses Credentialing Center

4
Study Nursing Units

• Sharp Memorial Hospital
• 2 Critical Care
• 4 Intermediate Care
• 4 Medical Surgical
• Total of 4000 patient Days

• Sharp Grossmont Hospital
• 2 Critical Care
• 3 Intermediate Care
• 2 Medical Surgical
• Total of 3500 Patient Days

5
Medication Order Management

• Physician written order
• Medication orders
• Faxed to Pharmacy entered into pharmacy computer
  system
• Entered into nursing documentation system
• Daily, manual reconciliation of written order and
  medications in the pharmacy and nursing computer
  systems
• Discrepancies among written order, order in
  pharmacy system, order in nursing system

6
Computerized Interface

• Interdisciplinary Team
• Nurses
• Pharmacists
• Physicians
• Information systems staff
• Goal
• Decrease incidence of preventable adverse drug
  events and non-intercepted potential adverse drug
  evetns

7
Definitions

• Adverse Drug Event (ADE) Causes patient harm
• Preventable ADE
• Non-Preventable ADE
• Potential ADE Potential to cause patient harm
• Intercepted Potential ADE
• Non-Intercepted ADE

8
Data Collection Methods

• Spontaneous Self Reports
• Medication Hotline
• Verbal reports to Research Associates
• Incident Reports
• Stimulated Self Reports
• Research Associate elicited reports during rounds
  and meetings
• Computer Alerts and Triggers
• Pyxis Profile Reports
• Medication triggers commonly used to treat ADEs
• Clinical Pharmacist Surveillance Reports
• 5 random chart review

9
Hospital Results
1 Incidence of cases per 1000 days 2 Fishers
Exact Test
10
Division Results
1 Incidence of cases per 1000 days 2 Fishers
Exact Test
11
Conclusion

• Pre and post evaluation recommended to accurately
  assess impact of health information technology
  solutions
• Electronic interfaces do not always solve patient
  safety problems
• Health Information Technology is a tool, not a
  solution to improve patient safety

12
Acknowledgements

• University of Nebraska
• Rita Snyder, RN, PhD
• Jane Meza, PhD
• Kelly Bosak, RN, PhD
• Brigham and Womens Hospital
• David Bates, MD
• Jeffrey Rothschil, MD
• Diane Seger, PharmD

• Sharp HealthCare
• Albert Rizos, PharmD
• Christine Tedeschi, RN, MSN
• Justine Foltz, RN, MSN
• Terry Myers, RN, BSN
• Karen Heaney, RN
• Joel Kunin, MD
• John LeMoine, MD

13
Thank You!Questions?