In the past decade, many examples of error, waste, and inefficiency in healthcare have been identified. In 1999, the Institute of Medicine (IOM) estimated that nearly 100,000 hospitalized patients die each year from medical errors.¹² The IOM report led to increased scrutiny of the safety and efficiency of the healthcare system. In 2003, the analysis by McGlynn and others⁹ documented a significant gap between the care that patients need and the care that is provided. In a sample of more than 6700 adult patients in 12 metropolitan cities, only 54.9% of patients received the recommended care.⁹

IT is a potential tool to reduce errors. A reduction in errors can result from the role of IT in managing information, its utility in standardizing care, and through its role as a vehicle to change roles and processes in an effort to reduce cost, variability, and waste. These efforts can result in improved outcomes (Fig. 23-1)

Fig. 23-1 Key drivers of healthcare information technology.

Information systems work by several mechanisms to reduce human error. The process of delivering good care is getting more difficult as the result of the sheer volume of data that clinicians must review and evaluate. This volume can range from the hundreds of data points to be analyzed from a patient’s vital sign flow sheet to the thousands of new journal articles written every year that can affect management of a disease or complication. The computer can be an excellent tool to help collate, retrieve, and store this information so that it can be used effectively. Reducing the reliance on human memory can help to mitigate situations in which care is delayed or omitted.

IT can help to improve healthcare delivery by simplifying processes. It takes a lot of time to fill out multiple requisition forms to communicate with a variety of hospital departments. Using IT tools, forms can be completed and routed electronically; this can reduce time for the entire care process and improve the delivery of care. Computer systems are also highly effective in ensuring completeness of a process. Through the use of constraints or forcing functions, such as requiring that a name be filled in or dose specified in the case of a medication order, the system as a whole can be made more efficient.

Computerized systems can be used to promote the use of standard protocols or checklists to ensure that providers undertake all necessary and effective care steps. These approaches all center on the concept of decision support. Decision support in a computerized system helps the user make the best patient care or management decisions by assembling all necessary information and by reducing the number of steps or processes to making the given decision. The effective use of these tools can decrease dependence on vigilance and reduce handoffs and redundant data entry, all of which have been shown to contribute to errors in healthcare.

Implemention of clinical information systems

Despite the great promise of electronic systems and substantial financial investment in such systems, there continues to be significant variability in the success of information system implementation and adoption by clinicians. According to the Office of the National Coordinator for Health Information Technology, almost one third of electronic medical records technology implementations fail. Healthcare providers and IT experts are now beginning to understand the challenges of introducing technology into clinical workflow.

IT implementation often fails because clinical users are unprepared for the additional burden that interaction with an electronic system will place on their work patterns and clinical care delivery. In addition, the systems must be developed with adequate input from the users, and careful planning for unique hospital needs. Several high-profile implementations of computerized provider order entry (CPOE) have provided excellent case studies to teach improved approaches to IT implementation.

A large hospital in Los Angeles implemented a multimillion-dollar CPOE system with little physician input. Shortly after implementation, clinicians complained that the system was not working and patient care was being compromised. Three months after implementation, the hospital was forced to uninstall the system.

In another case, in the first 5 months following implementation of a commercially purchased CPOE system in a pediatric critical care unit at a leading children’s hospital in the northeast, mortality during interfacility patient transfer more than doubled (from 2.8% to 6.6%) when compared with the mortality in the 13 months preceding CPOE implementation.³ Several factors may have contributed to this rise. First, the system was rapidly deployed. Second, the clinical care team was not allowed to enter orders until the patient physically entered the hospital. Third, order sets were not developed to help clinicians rapidly enter common orders. Fourth, simultaneous with the CPOE implementation, the hospital dispensing process for medications was changed. All of these factors directly affected patient care.

A second children’s hospital in the northwest installed the same commercial CPOE system. When the effects of the implementation system on the northwest children’s hospital was studied by Del Beccaro and others,² they found no difference in mortality in the preimplementation and postimplementation periods.

The Agency for Healthcare Research and Quality (AHRQ) calls for careful and thoughtful implementation of CPOE systems. Koppel’s study of CPOE systems, funded by the AHRQ,⁷ found two key problem areas in implementation:

• Fragmentation of data among each hospital’s various information systems

• Interface problems between people and machines, particularly when the computer forced people to work in a way that differed from clinical work routines

People, Process, and Technology

Unlike simple electronic tools that automate a single task, the introduction of clinical IT involves a dynamic set of interactions that all have to be managed effectively. The categories of people, process, and technology each introduce different challenges and factors that must be addressed for successful IT implementation and adoption.

The people involved in IT implementation include individuals and groups with an interest in the project. It is clear in the previous example of the large Los Angeles hospital that the primary users of the CPOE system, the clinicians, had inadequate input during the design or implementation process. Unfortunately, clinician input is often inadequate in IT implementation projects; however, this might not result from the specific exclusion of clinicians by the project team. The clinical environment is demanding and often the clinicians who have the most clinical experience and insight are unable to break away from their clinical responsibilities to participate in the process.

It is essential to acknowledge the challenge of clinical user involvement and to develop strategies to address it. Administrative leaders must acknowledge that time devoted to large implementation projects is important, and these leaders should consider compensating participant staff for involvement in such projects. Institutions that have taken this approach have seen significant improvements in clinician commitment and engagement.

The clinicians who participate in and lead implementation projects should possess several key skills. Technical expertise is not an essential skill, and it often can be a distraction. Foremost, the clinician must have the respect of and credibility with his or her peers. The value of peer-to-peer education, advocacy, and persuasion cannot be overstated. Healthcare providers learn best from colleagues rather than from didactic sessions. The clinician must also have a good understanding of the actual clinical workflow that will be affected. It is this understanding that allows the implementation team to identify potential pitfalls and obstacles that can derail a project plan.

The involved clinician must be able to work collaboratively with colleagues from a variety of clinical and nonclinical disciplines. The clinician must help the project team understand clinical realities and also must understand the capabilities and limitations of the technology. The clinician should be able to help the group make the correct adjustments and appropriate compromises so that the technology can be easily adopted and used effectively.

The likelihood that a person will use new technology depends to some extent on individual factors. A known predictor of technology adoption is the confidence that an individual has the ability to use the tool effectively. This concept is called self-efficacy. Healthcare workers with low computer self-efficacy often have difficulty adapting their workflow to incorporate the use of computers.

Different units in the same hospital will have drastically different acceptance of the same technology as the result of differences in staff perceptions regarding the ease of technology use and also the result of differences in staff attitudes about changes in their practice. Gender and age play important roles in determining these perceptions and attitudes. Karsh ⁴ found that male users valued the usefulness of a tool, whereas female users felt that ease of use was more valuable. Older users focused more on social and process issues, whereas younger users focused more on the effects of the tool on task performance. Therefore before implementing any new technology, planners should evaluate characteristics of potential users and of the potential technology itself.

In order for technology to contribute to improvements in process, planners must be knowledgeable about all aspects of the process. Planners must evaluate and understand the rationale for each discrete step and each task in the process, and they must understand the communication needs at every level. Too often, introduction of new technology (e.g., an electronic system), even if it is designed to mimic existing workflow, will exacerbate a variety of poor processes that were previously not identified as problematic. Simply stated, if there is a bad process, then the introduction of technology can, at best, automate that bad process. The act of implementing an informatics solution can be the impetus to redesign and improve workflow or at least identify where the technology may exacerbate poor workflow.

Hospital policies and procedures are often reviewed for guidance when the evaluation of workflow reveals significant variability or a clear breach of appropriate standards. During this phase, it is important to note that the clinicians often adapt a given process to deliver care within the constraints or flaws of an existing system. The plan should address the gap between clinical practice and existing policy. IT implementation will not be successful if technology is used in an attempt to force compliance with standards that clinicians have already rejected. Before attempting to implement a technology solution, planners must revisit the rationale for the existing standards, gain consensus with the clinicians, and redefine the process with all stakeholders. Administrative leadership is a key element in advocating for changes in policies and procedures while maintaining compliance with external regulations and accreditation standards.

Technology itself can introduce problems or complications that can produce a variety of unintended consequences. The staff members at the northeast children’s hospital pediatric critical care unit (mentioned previously) discovered the limitations of CPOE technology that only allowed order entry after the patient arrived in the unit. The technology was a potential contributor to delays in care associated with increased mortality after deployment of the CPOE system.

The usability of the technology will obviously affect adoption and success. In general, consumers have high expectations for a good user experience as the result of advances in the consumer world and the effects of Internet capabilities in everyday lives. Unfortunately, many healthcare technology tools are not able to offer the robust features that are prevalent in the consumer world.

Technology accessibility can have a significant effect on the success of informatics tools used in the hospital environment. Too often, projects underestimate the number and types of devices that will be needed to effectively use the tools in a given workflow. Because most IT tools are accessed via a computer, it may be challenging to have a sufficient number of devices available to meet the demand of end users. Whereas the cost of devices has dramatically decreased in recent years, the physical environment, the cost of appropriate mounts or carts, and the need for mobility are parameters that may complicate or prevent successful implementation.

In order for good tools to be useful, clinicians must be able to access a computer at the time or in the place the tool is needed to deliver good care. This is of particular relevance in the critical care setting, where bedside clinicians require immediate access to a computer in the patient’s room to use technology solutions, such as bar-coded medication administration. Use of a mobile computer allows significant flexibility for the provider within the room, but satisfaction greatly diminishes if the provider is expected to move the device from room to room when caring for more than one patient. Mounted computers are useful in the hallways and common desk areas in patient care units, but they may be less accessible in a critical care room, where the provider is often surrounded by a lot of other equipment.

Evaluating any informatics tool across the categories of people, process, and technology can provide important information. The implementation and adoption of any technology is enhanced when this information is included in the analysis and project plan.

Best Practices

A set of best practices have been identified that can increase the chances of successful implementation and adoption of information technology tools.

From Upperman JS, et al: The introduction of computerized physician order entry and change management in a tertiary pediatric hospital. Pediatrics 116:e634-e642, 2005

Clinical information systems

The focus on medical safety stimulated by the 1999 Institute of Medicine ¹² report led to the formation of the Leapfrog Group for Patient Safety. This group consists of many large companies and organizations that pay for healthcare coverage for their employees. The group initially named three key practices that could significantly improve healthcare quality and safety. These three practices are:

1. Use of CPOE

2. Evidence-based hospital referral (choice of hospitals and referrals should be based on a hospital’s experience and outcomes, particularly for complex procedures), and

3. Staffing of pediatric critical care units with physicians experienced in critical care medicine

Computerized Provider Order Entry

There are many reasons why CPOE is expected to improve healthcare quality and safety (Box 23-2). CPOE systems can aggregate data for clinical use. Unlike the paper ordering process, a clinician can interact with the system away from the bedside without relying on verbal or telephone orders, which can lead to potential errors. Because communication is electronic, CPOE systems immediately route orders and requisitions to ancillary departments.

Box 23-2 Key Advantages of a Computer Provider Order Entry System

• Key data are aggregated for clinical use

• Clinician can interact with the medical record away from the bedside

• Immediate routing of orders and requisitions to ancillary departments

• Smart prompts and checks can enhance safety and quality of care

A major focus of CPOE systems is improving the ordering of medications and their accuracy. Several studies have shown that the use of CPOE can significantly reduce medication errors. CPOE improves the process by virtually eliminating orders that are incomplete or illegible or have abbreviations. This improvement markedly increases the efficiency of the ordering process and diminishes communication errors.

Additional improvements in ordering medications result from safety checks that allow the system to alert the provider to patient drug allergies. Obviously, the CPOE system cannot provide alerts unless valid information about patient allergies is entered into the system. Each clinical unit must develop a standardized process for identifying patient allergies and correctly entering this information into the information system. The robustness of a given system rests on how well it facilitates this process.

Clinical Decision Support

Clinical decision support within the CPOE system can help to reduce medication errors. Standard decision support algorithms can alert a prescriber if an ordered dose falls outside a predefined range of acceptable dosing. In a pediatric setting these alerts may still be insufficient unless they factor in the effects of patient weight and age on an appropriate medication dose.

The next generation of CPOE systems is beginning to incorporate decision support. Decision support can be expanded to include parameters such as renal function, immune status, and eventually genomics and proteomics in dose alerts.

Order Sets

An order set is a group of related orders that can be presented to a clinician for selection. These orders can provide the standard approach to treating a particular disease process, such as community-acquired pneumonia, or they can consist of a common set of orders that are needed for the postoperative care of patients after common procedures such as an appendectomy. Order sets for high-volume clinical conditions can incorporate evidence-based medicine and reduce variations in care among clinicians. Order sets can also be created for relatively low-volume cases in which precision is of paramount importance. A standard order set for a transplant patient with graft-versus-host disease is an example of the need for precision. Each order set should follow a specific protocol established by institutional experts and can be available instantly for to the prescribing clinician. The order sets support delivery of optimal evidence-based care for each patient.

The percentage of total orders entered into a CPOE system though order sets is directly correlated with the adoption of the CPOE system. As more evidence-based treatment approaches are selected, the quality of care improves and benefits of the CPOE system become more apparent.

Many institutions have already developed treatment protocols in the paper ordering process. These protocols are the best place to begin designing CPOE order sets. Facilities with significant experience with CPOE have found that the energy and resources available during the implementation phase of CPOE wanes over time. During the maintenance phase of the CPOE system, it important to establish a process for periodic review and update of order sets with continued incorporation of the latest evidence from the healthcare literature to guide clinical care (Fig. 23-2)

Fig. 23-2 Order sets with links. This diagram shows the relationship among traditional order sets with links to the reference material for evidence-based medicine developed by the Evidence-Based Medicine Team at the Vanderbilt University Medical Center.^11a

(Courtesy Zynx Health Incorporated, Los Angeles, CA; and Vanderbilt University Medical Center, Nashville, Tenn.)

The project team can often leverage existing hospital process improvement infrastructure to help establish a systematic process for developing order sets (Box 23-3). The first step in building the infrastructure is to identify the core team that will serve as the resource for the institution. Because order sets can exist for each of the clinical disciplines, it is important for the core team to work with key representatives of the patient care team so that the clinicians have confidence in the process and a sense of ownership of the order set content. Minimizing the time commitment by the clinicians will help retain their engagement. The core team should be responsible for coordinating meetings, collating the necessary documents, and filtering the literature. This process frees the clinicians to focus on important clinical content.

Box 23-3 Sample Evidence-Based Practice Process for Development of Order Sets ^11a

Define Order Set Team

• Evidence-based practice (EBP) specialist

• Librarian consultant

Input Phase

• Clinical team and target order sets are identified.

• EBP specialist and team leads gather relevant clinical evidence.

Library, Zynx Health Incorporated, Cochrane database, national guidelines, medical literature

Core measures

• Evidence-based practice (EBP) specialist creates an evidence packet with order sets and targeted evidence.

• Initial development meeting is convened.

Implementation Phase

• Order set creation in the CPOE system

• Pathways created for multidisciplinary use that incorporates order set data

• Evidence Web—key clinical evidence linked to order set made available in a reference portal

• Feedback obtained throughout process

CPOE, Computerized provider order entry.

Alerts and Cross-Checks

Advances in CPOE technology include several features to promote excellence in patient care delivery. These features will be most effective if content is adjusted to match closely with the clinical context in which it is used. There must also be a constant balance between utility and overuse. Although prompts and reminders are viewed as helpful by clinical users, if they disrupt thought processes or are presented out of context, users will quickly develop workarounds to avoid features that are intended to be helpful or improve safety. Similar to the consumer response to a barrage of pop-up messages during Internet use, healthcare users may develop alertfatigue and begin to cancel or close the alert feature without reviewing the content. This scenario defeats the purpose of the safety aids and should be avoided at all costs.

Some features are designed as cross-checks to ensure that every order is clinically appropriate for the patient. In the area of medication ordering, drug allergy checks and drug-drug interaction (DDI) alerts are good examples of these cross-checks. Good clinical practice requires a check to verify that a patient does not have a known allergy to a prescribed drug. Unfortunately, this check is often omitted. A variety of factors contribute to the problem; the most common is that information about the allergy is not available to the prescribing clinician at the time the medication is ordered. A CPOE system closes this gap with a drug allergy check, but it cannot eliminate the gap. The computer system is dependent on accurate entry of allergy information for every patient.

The benefit of a CPOE system is that once patient allergy information is entered, it can be helpful for every instance of medication prescription. Based on the sophistication of the CPOE algorithms, a single entered allergy can prompt an alert for any potential medication prescribed in the same general class of medications (e.g., sulfonamides or penicillin class drugs) that can trigger a reaction. It is important to note that not all allergies have the same clinical effect, and a clinician needs to have as much information as possible about the severity of the allergy to make the best clinical decision. There are times that the clinical benefit of a medication outweighs the potential for an allergic reaction.

A DDI is any situation in which one drug has the potential to increase or decrease the effect of another drug to an extent that is clinically significant. Ideally, a prescribing clinician is alerted to this possible situation during the order entry process and will be guided toward a better clinical decision. In a study by Ko and others ⁶ of providers and pharmacists who used the U.S. Department of Veterans Affairs CPOE system, most felt that DDI alerts increased the safety of prescribing practice. The caveat from this study was that fewer than one third of the prescribers found that the system gave the essential information necessary to make good decisions. Both the prescribers and pharmacists felt that for DDI alerts to be effective, the system should give more detailed information and should suggest appropriate alternatives.

A CPOE system can prompt providers to add corollary orders. An example is a reminder to order drug level testing if antimicrobial therapy with an aminoglycoside is ordered. The system can provide a reminder to order an activated partial thromboplastin time test if a patient is given an anticoagulant. The efficacy of these alerts depends greatly on the timing of their appearance. Alerts that open immediately and interrupt clinical thinking and workflow can be met with resistance. Providers will accept these interruptions if they indicate a gross error or potential patient harm. However alerts that serve as simple reminders are viewed as a nuisance and are often ignored.

The concept of an exit check is of great utility for alerts regarding corollary orders. Exit checks appear after the provider has completed the ordering process and is ready to exit the CPOE session. By this time, the clinician has had an opportunity to address the issues that require alerts, but the alerts appear if issues remain when the provider is ready to review the orders. Exit checks are viewed as being less intrusive to workflow, so they have had greater acceptance.

Pediatric medication safety

There are four steps in medication delivery: prescribing, transcribing, dispensing, and administering. Errors can occur at each step, but approximately 80% of medication errors occur at the prescribing and administering steps ¹:

• Prescribing—56% of errors

• Transcribing—6% of errors

• Dispensing—4% of errors

• Administering—34% of errors

Thus, systems focusing on reducing medication errors have focused on the prescribing and administering phases of medication delivery.

A major goal in the development of CPOE systems is improving the prescribing phase of the medication delivery process. Many studies have shown dramatic reductions in adverse drug events and medication prescribing errors with the implementation of CPOE systems.

Pediatric Medication Dosing

The use of CPOE in the pediatric population requires a special focus on dosing algorithms (Box 23-4). The process of dosing medications for the pediatric patient is distinctly different from the process used in adult patients. Pediatric medication dosing is based primarily on patient weight. In certain subpopulations, dosing differs based on the age of the patient in both chronologic and gestational terms. In neonatal patients, rapid weight changes that are significant as a percent of weight must also be considered. If weight-based dosing is used, some school-aged patients can surpass adult dosing recommendations on a milligram per kilogram basis. A CPOE system must be able to integrate these factors into appropriate decision support (Fig. 23-3).

Box 23-4 Key Aspects of Pediatric Medication Dosing

• Weight-based dosing

• Age-specific algorithms

• Issues of gestational age

• Rapid weight changes

• Complex calculations for drugs that are delivered by continuous infusion

Fig. 23-3 Decision support tools. A sample view of decision support tools in a CPOE system to facilitate medication ordering for pediatric patients.

(Courtesy of Vanderbilt University Medical Center, Nashville, Tenn.)

In critical care units, the process of ordering continuous infusion medications is more complex for pediatric patients than for adults. The medications for pediatric patients are typically dosed on the basis of weight. The infusions can be prepared with standard concentrations, and the flow rate needed to deliver a specific dose varies based on the patient’s weight. In the past, the concentration of the infusion varied according to the patient’s weight so that the same infusion rate delivered the same dose for all patients. The latter was the basis of the classic “rule of sixes.” Currently most hospitals use standard concentrations for continuous infusions.

The calculations for both standard and weight-based concentrations, such as the rule of sixes, can lead to confusion and errors. In the paper-based ordering process, prescribers often did not provide the complete information necessary for pharmacists and nurses to cross-check the calculations. A CPOE system with effective clinical decision support can significantly improve the prescribing process for continuous infusions by performing the complex calculations, ensuring completeness of the orders, and producing a titration table against which intravenous pump settings can be compared by nurses administering the drug (Fig. 23-4). This final check by the nurse at the point of care is crucial.

Fig. 23-4 Ordering screen for continuous infusion medications. This is an actual ordering screen for prescribing continuous infusions of drugs such as dopamine. This screen displays key features of advanced CPOE systems, such as dose and concentration calculator, dose recommendations, and titration tables to correlate dose and fluid rate.

(Courtesy of Vanderbilt University Medical Center, Nashville, Tenn.)

Pediatric Patient Specific Decision Support

When a critical care environment transitions to an electronic ordering system, the project team should evaluate several system features and develop a standardized approach to address common pediatric dosing issues (Box 23-5).

Box 23-5 Key Features of Patient Specific Decision Support

• Provides weight- and age-specific dosing information at the time of ordering

• Menu dose options provided in mg/kg or mg depending on weight of patient

• Calculations performed by the computer

• Only intervals and doses appropriate for the specific patient are presented to the prescriber

• Doses rounded to standardized values

• Dose-check warnings provided for single doses

The most basic feature of any electronic ordering system determines the types of information that must be entered before an order is accepted or completed. Many institutions require the entry of a pediatric patient’s weight to increase dosing accuracy. However, in pediatric units where patients are weighed daily, especially neonatal units, this requirement could result in daily changes in medication doses that would be impractical. In addition, providers should have a consistent process regarding units used for weight (grams, pounds, kilograms) and to verify the weights entered. Providers can use a medication dosing weight, in a fashion similar to the use of dry weight for patients with renal failure. Use of a medication dosing weight allows the CPOE system to anchor the calculations of medication doses to values that are set by the prescriber, and it also allows the clinical care team to enter patient weight values as clinically indicated.

Another important feature to address in the electronic ordering system is the process for frequent changes to therapy, such as ventilator changes and titration of continuous infusions. If the CPOE system requires a lot of time and effort to enter orders for each change, providers could resist using the system or fail to comply with order entry. It is important for unit and institutional policies to be in place to address this clinical reality.

Overall, the use of CPOE can be highly effective in reducing medication errors. The presence of advanced decision support markedly improves the utility of CPOE, especially in the care of pediatric patients.¹¹

The Five Rights of Medication Administration

The core checks for appropriate medication administration are the well publicized “five rights” (Box 23-6), which are right patient, drug, dose, route, and time.

Box 23-6 The “Five Rights” of Medication Administration

Bar-Coded Medication Administration

Bar code technology has been proposed to improve the safety of medication delivery during the medication administration phase. This technology provides an objective method to check the patient and the accuracy of the medication during the medication administration process.

The standard process for administering medications requires mental checks of the labeling on the syringe, the medication administration record, and the patient arm band, even after the checks for propriety of drug and dose. Many medications have similar packaging and labeling that can contribute to medication errors.⁵ There are tragic examples of overdose of drugs such as heparin resulting from such similarities.

The bar-coded medication administration (BCMA) system uses bar code technology to cross-check the patient’s arm band bar code and the drug bar code against a system containing the medication orders for the patient to confirm that the patient should receive that drug in that dose at that time (Fig. 23-5). Alerts should be raised if the orders do not indicate a match of the drug dose, the patient, and the time. The BCMA system requires that all steps be followed and that the provider acknowledge the alerts.

Fig. 23-5 Use of bar-code during medication administration. A, Bar-coded medication administration involves scanning the medication and B, then scanning a patient identification band.

BCMA technology must be incorporated into nursing workflow to be effective. There have been many anecdotes of workarounds that enable nurses to bypass the system, thereby nullifying its effectiveness as a safety check. The drug and the patient’s arm band should be scanned to ensure that the correct patient is receiving the correct drug in the correct dose and by the correct route at the correct time.

Implementation of BCMA technology can be successful using the principles described earlier in this chapter. BCMA systems have been used across the United States, with a variety of different vendor products. Many systems have reported near-misses when alerts from the BCMA system prevented administration of an incorrect drug or drug dose to a patient. It is difficult to determine the actual reduction in medication administration errors resulting from the BCMA technology, because few objective data exist to determine the actual medication error rate before implementation of BCMA systems.

BCMA technology is used in the pediatric setting, but several issues can complicate its implementation and effectiveness. One of the key elements in BCMA technology is the presence of a barcode on the medication to be delivered to the patient. The bar code is scanned and the drug, dose, and route of delivery are checked against the patient’s medication administration record, which lists the drugs prescribed for the patient. The barcode on the medication can be the original barcode placed on the packaging by the manufacturer or the barcode placed by the pharmacy when dispensing the medication. The bar code must contain the drug name and the dose of the medication. This process is especially important for intravenous medications that have been prepared by the pharmacy and dispensed to the bedside for administration. When the pharmacy is involved in the dispensing process, the BCMA workflow is fairly straightforward; the pharmacy can create a bar code that contains the information regarding the drug and dose.

Many institutions use unit-based medication cabinets to store unit doses of medication that can be dispensed by nurses. The self-dispensing process can complicate the use of the BCMA if the dose of the medication to be administered differs from the unit dose available in the medication cabinet. This is often the case for pediatric patients: the dose prescribed and administered often differs from the manufacturer-provided unit dose. The BCMA system is not able to cross-check the actual dose, and an alert will be generated whenever the scanned dose from the cabinet differs from the dose to be administered. For example, when 0.5 mg of midazolam is prescribed for a 5-kg patient, the nurse is expected to draw or dispense the 0.5-mg dose from the unit dose vial (stored in the medication cabinet) that contains 2 mg. If the nurse simply scans the barcode of the unit dose file, an alert will result, because the vial contains 2 mg, not the 0.5 mg that was ordered. This alert does not indicate a limitation of the BCMA application as much as a reflection of the workflow that bypasses the pharmacy in the dispensing phase of the medication delivery process. In patient care units where patient medications are obtained from medication cabinets, education of the staff is essential. The alert indicating “wrong dose” should be viewed as a safety check, reminding the nurse that the entire unit dose from the medication cabinet should not be administered to the patient. Nurses should record the drug dose actually administered to the patient.

The implementation of an electronic system will create many opportunities for improving the medication administration process. The data provided from the BCMA system can be used to focus improvement efforts and target areas of the process that require modification or enforcement of existing policies. It is essential to focus on improving the overall system rather than criticizing individual behavior. The punitive nature of medication error reporting needs to be eliminated. The goal is to create processes that prevent errors; careful study of errors can help to identify the parts of the process that should be changed or improved.

In an evaluation of BCMA use and the types of workarounds that users create, Koppel and others ⁸ were able to group the workarounds into three general categories:

1. Omission of process steps

2. Steps performed out of sequence

3. Unauthorized process steps

Analysis of the probable causes of these workaround categories identified five distinct issues that contributed to use of workarounds:

Organizational causes: issues related to inadequate policies, training, staffing or other areas that are governed at an organization level. For example, if the unit dose provided is consistently too large for every pediatric patient, and the nurse must always draw up a tiny fraction of that unit dose, then each time the drug is used there is an opportunity for imprecision in drug dosing or overdose.

Environmental causes: issues related to the logistics of space, positioning, and location of key items necessary to use BCMA technology. For example, if there are insufficient bar code scanners available for the pediatric critical care unit, or if the medication cabinet and the scanners are stored in different places so that the nurse spends a great deal of time getting the medication and finding a bar code scanner, then these issues will delay medication delivery and complicate the nursing workflow.

Overall, the use of BCMA technology has great potential to improve the safety of medication administration. The effects of the safety improvements and the effects on clinical workflow and outcomes continue to be evaluated.

Electronic clinical documentation

Many institutions are transitioning clinical documentation from the traditional paper medical record to an electronic system. Critical care units have moved to computerized charting well ahead of other in-hospital units. The large amount of monitoring data and the frequency of recording needed has provided the impetus for the move to electronic solutions.

A key benefit of electronic documentation is that the clinical team has access to charted data for review and analysis away from the bedside. This benefit is only realized if the bedside provider uses the computerized system efficiently to ensure timely data entry and appropriate communication of changes in the clinical scenario.

Traditional nursing documentation relied on narrative documentation. The transition to electronic systems will force a change in this documentation style. The shift in approach can create anxiety, confusion, and frustration. With computerized documentation solutions the nurse’s clinical observations, treatment applications, and patient assessments are distributed into multiple data fields and separate documents in the electronic record; they no longer tell a story in narrative form.

The benefit of the computerized approach is that specific data elements are easier to find, and the system can manipulate the data elements for more effective data display and for analysis through the use of data queries. The electronic system should take advantage of this latter feature rather than attempt to retain the narrative form and force large amounts of free text into comment fields.

It is challenging to strike the right balance between data standardization and effective communication; this requires a thoughtful institutional approach. Implementing electronic documentation exposes the variability in nomenclature and standards among different groups of providers. If existing documentation patterns are simply translated into the electronic tools without standardization, the tools will contain many different methods of describing clinical findings, with little structure or definition. As an extreme example, one institution included 18 potential color choices to describe urine.

Excessive variability among users and providing too many choices within the data base will have a negative effect on communication. The system will be difficult for the clinician to navigate, and it will accumulate large amounts of data that will be difficult to analyze or use effectively. Communication will be more efficient and effective if data standards are created and adopted by all clinicians.

Just as in the use of CPOE for providers, electronic documentation can prompt completeness in charting by nurses (Fig. 23-6). In both the CPOE and electronic documentation, prompts must be used judiciously to minimize disruptions and support effective clinical communication, documentation, and workflow. Effective use of forcing functions requires titrating disruptions to their level of importance for clinical care. Forcing functions should be reserved to prompt entry of data that is essential either for the safety of the patient or to fulfill a regulatory requirement that all agree is a priority.