Transcript Electronic Prescribing - Neonatal and Paediatric Pharmacists Group

Electronic Prescribing: Friend or Foe? An
audit of prescribing errors after the
introduction of an electronic prescribing
system in neonates and children.
Maria O’Meara, Kings College Hospital
Electronic Prescribing : Friend or
Foe?
Marie O’Meara
Paediatric Liver Pharmacist
King’s College Hospital NHS Foundation Trust
Honorary Clinical Lecturer KCL
&
Naumann Shaheen
University College London
Background
• Variety Children’s Hospital, 100 bed paediatric
centre. National, tertiary and local services
• Numerous Strategies to reduce medication errors
• Paediatric prescribing error rates 5-27% (Miller et al 2007)
• 8 studies investigating the effect of Electronic
prescribing on prescribing error rates in children
Electronic Prescribing & Medicines
Administration System (EPMA)
• EPMA- commercially available system produced by
iSOFT PLC
• No Clinical Decision support systems (CDSS)
• First introduced at KCH in 2009
• Rollout to Women’s & children’s services Oct 2012
• Staggered, completed Jan 2013
EPMA in Paediatrics
• Separate paediatric drug catalogue adapted from the
adult catalogue. Choice of drugs available limited
• Paediatric specific order sets for complex patient
groups
• All staff had mandatory training prior to the
implementation
• 24 hour support available during rollout period
Aims and Objectives
• To audit the number and rate of prescribing errors over a
two week period
• To identify the common types of prescribing errors
• To assess the clinical significance of the errors
• To compare the rate, nature and clinical significance of
prescribing errors to the previous year (paper) to
ascertain the impact of EP.
• To make recommendations based on results obtained.
Definition of a prescribing error
• ‘A clinically meaningful prescribing error
occurs when, as a result of a prescribing
decision or prescription writing process, there
is an unintentional significant (1) reduction in
the probability of treatment being timely and
effective or (2) increase in the risk of harm
when compared with generally accepted
practice’
-Dean et al.
Methods
• Prescribing errors, prospectively recorded
pharmacists (n=5) & technicians (n=1) on ward
rounds/visits over 2 weeks
• Neonates excluded, PICU- Metavision
• Each error allocated a code, corresponding to one of
33 scenarios
-Ghaleb et al 2005
• Clinical significance determined using a validated
method. 4 healthcare professionals (1 consultant, 2
pharmacists and 1 nurse)
-Dean & Barber 1999
• Data were analysed using Microsoft Excel
Results
2012 (pre EPMA)
• Error rate
– 1117 medication orders
– 95 errors
– Error rate 8.5%
2013 (post EPMA)
• Error rate
– 1147 medication orders
– 180 errors
– Error rate 15.7%
• Clinical significance
• Clinical significance
– Minor 18.6%
– Moderate 80.4%
– Severe 1%
– Minor 26.6%
– Moderate 73.4%
– Severe 0%
Change in pattern of errors
Error type ↑post EPMA
• Prescribing dose/frequency
that is not recommended
for the formulation
prescribed
• Continuing a prescription
for longer than necessary
• Unintentionally not
prescribing a drug for a
condition for which the
drug is indicated
• Duplication
• Formulation
Error type ↓ /omitted post
EPMA
• Writing Illegibly
• Misspelling a drug name
• Omission of the prescribers
signature
• Writing a drug name using
abbreviations
• Dose written as mg/kg
rather than final dose
• Prescribing a prn drug
without a max daily dose
• Allergy status ommitted
Drugs most associated with errors
2012
Drug (%)
2013
Drug (%)
•
•
•
•
•
•
•
•
•
•
Paracetamol (17.9)
Gentamicin (3.2)
Morphine (7.4)
Tacrolimus (4.2)
Ursodeoxycholic acid (3.2)
Morphine (7.2)
Methylprednisolone (4.4)
Paracetamol (3.9)
Hydrocortisone (3.3)
Phenobarbitone (3.3)
Limitations
• Voluntary reporting? Under reporting prior,
inconsistent with literature
• Snapshot (2 weeks)
• EPMA – newly introduced
• Point in prescribers rotation
• Detail not always sufficient to rate significance
Post audit implementation &
Future work
•
•
•
•
•
Policy for weaning introduced
Frequency & routes rationalised
Upgrade of system 2014, ↑CDSS
Large multicentre study required
Electronic Prescribing in Pediatrics: Toward Safer
and More Effective Medication Management
Johnson et al Pediatrics 2013;131;e1350
– Paediatric requirements for safe and effective
electronic prescribing
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
TABLE 1 Pediatric Requirements for Safe and Effective Electronic Prescribing
Category
Pediatric Requirements
Patient information Date of birth or age in units more specific than years
Weight in kg
Height in cm
Any history of intolerable adverse effects or allergy to
medications
Medication information
Indication-based dosing and individual and daily dose alerts,
using mg/kg per day or mg/m2 per day formula, unless
inappropriate
Weight-based dosing calculations
All available formulations, including liquid formulations that
may be specific brands
Common formulations requiring extemporaneous compounding
or combinations of active ingredients
Cognitive support Dose range checking (minimum and maximum amount per
dose, amount per day based on weight, surface area,
and total dose)
Automatic strength to volume conversions for liquid
medications
Adverse-effect warnings specific to pediatric populations
Alternative therapies based on ameliorable adverse effects
Tall-man lettering to reduce medication selection errors
Medication-specific indications to reduce ordering of
sound-alike drugs
Pharmacy information Pharmacies that will create extemporaneous compounds
Data transmission Use of messaging standards for data transmission to
pharmacies that include the patient’s weight and notes
pertaining to weight-based calculations
Transmission of strength, concentration, and dose volume
labeled in metric units for liquid medications