Tracey Watson - Taranaki DHB - HiNZ 2015 Conference, Christchurch

1. Learning’s from an Ad Hoc Evaluation of the
Taranaki DHB (TDHB)
ELECTRONIC PRESCRIBING PILOT

2.  1/3 National Pilot Sites
 TDHB INTEGRATION focus
 MedChart v6.3 with
 limited decision support
 1 way interface ePharmacy
+ ePharmacy
 1 way interface with Pyxis
+ Pyxis
+ eMedRec
Background

3. Electronic Prescribing
“not just a technology –it is a complex design / redesign
of clinical processes that integrates technology to
optimise physician ordering of medications. By its nature it
reconfigures hospital operations and workflow and
affects virtually all operations”
What we knew…

4.  End User perspective
 24/7 multi-user access from anywhere
 100% clear, complete prescriptions
 Decision support Allergies, Duplication, Interactions, Dose Ranges, Rules
 Medication Information Interaction checker, Datasheets, TDHB protocols
 Integration of tasks Administration, Pharmacist Review
 Integration of systems Allergies, Dispensary, Laboratory
What we knew…

5.  IF DONE WELL …improves outcomes
 MedChart v5.1 (St Vincent’s, Sydney)
 Reduces error rates by 60%
 Compared to 5-10% for National Drug Chart
 Type
 procedural errors 
 clinical errors
 serious errors 
 Remaining 40% errors
 15% errors introduced by the system ” eg Wrong strength / Timing
= FOCUS OF THIS PRESENTATION .
What we knew…

6.  IF DONE WELL…improves outcomes
 Workflow
 No changes in time spent
 in direct care
 on medication related tasks
 Prescribers spent  time with doctors & patients
 Nurses spent  time with doctors
What we knew…

7.  BUT its NOT a magic bullet
 Can contribute to errors
 Unintended consequences expected 1
 Increases mortality if poorly implemented 2
 Environment matters more than the system 3
1. Campbell E et al. Types of unintended consequences related to CPOE. JAMIA 2006; 13(5):547-556.
2. Han YY et al. Unexpected increased mortality after implementation of a commercially sold computerised physician order entry system.
Paediatrics 2005; 116(6):1506-12
3. Metzger J et al. Mixed results in the safety performance of computerised physician order entry. Health Affairs 2010; 4: 655-663
What we knew…

8.  Also will …
 NOT … fit everything on one page
 NOT … stop scripts being “CLEARLY” wrong
 NOT … stop you doing something stupid
 NOT … make clinical decisions for you
 NOT … replace communication with staff
What we knew…

9.  Complex
 CONTEXT is everything
 HOW is as important as WHAT
What we knew…

10. What we knew…
…the VALUE PROPOSITION…
...Will need to learn to do things differently,
but there will be benefits in return…

11.  In the TDHB context
 Implement safely?
 What were the unintended consequences?
 What were the new types of errors ?
 How could we mitigate the risks associated with these?
What we wanted to know…

12.  Use existing data where-ever possible
 Extensive baseline
 Monitored at 4, 8 & 12 months
 Quality improvement approach
 Started with subset of Pilot ward to understand TDHB
context & validate / refine workarounds
 < 4 months 17 patients 3 prescribers
 ≥ 4 months 25 patients 48 prescribers
 Pro-actively engage end-users & promote feedback
Approach

13. Approach

14.  Prescribing Audit
 Medication Safety Database Errors Grade 1-5
 Pharmacist Interventions Errors Grade 1-3
 Pharmacist Contributions
 Pharmacist Ward Education Log
 Ward Event Log
Monitoring

15.  Each Audit
 Subset of results
 Strategies used
 Training / Education
 Configuration
 Workflow
 Enhancement requests
 Lessons learned
Outline

16.  Compliance with TDHB Prescribing Guidelines 59 parameters
 Completeness
 Legibility
 Legality
 24hr snapshot n=2413 prescriptions
 All prescriptions vs Pilot ward 2012
 Pilot ward paper vs electronic 2012
 electronic scripts 8.4% All & 32% Ward
Prescribing Audit

17.  Legibility  to 100%
 Legality  to 100% - except for dose
 Completeness - Patient
 flagging of supplementary charts
 allergy documentation
 re-chart dates
 numbering of multiple charts
Prescribing Audit

18.  Completeness – Drug
 ceasing
 modifications
 minimum dose intervals for PRNs
 compliance with generic prescribing
 use of review/stop dates
 dose range guidance
 use of indication
Prescribing Audit

19.  Actions
 Enhancement requests Vendor / NeMP
 Dose forms that require dose creams & ointments
 Unapproved abbreviations mcg & IU
 Review date function medicine not drop off chart
 Lessons Learned
 Small changes for 100% legality (& legibility)
 Completeness improved in most instances
Prescribing Audit

20.  2 years pre & 1 year post n=1119
 Pilot ward 6.6% All errors (n=78)
 2 year pre 65% (n= 48)
 1 year post 35% (n= 26)
 Sub-analysis 4, 8 & 12 months
 Place in Medication Use process
 Type of error
 Factors involved
Medication Safety Database Grade 1-5

21.  88% events involved MedChart
  after 4 mths when pilot expanded
  end user reporting by 12mths
 Place in Medication Use process
 Prescribing 39% (Transcribing 56%)
 Administration 57%
 Pharmacy 4%
Medication Safety Database
0
5
10
15
20
25
4mth 8mth 12mth
Period
REPORTED ERRORS

22.  Medication Safety Database (Grade 1-5)
 Types of Error
 Extra dose 60%
 Withholding 64%
 Wrong start date 29%
 Wrong strength 8.7%
 Wrong time 8.7%
 Omission 8.7%
 Wrong patient 4.2%
 Duplication 4.2%
 Missed dose 4.2%
Medication Safety Database

23.  Medication Safety Database (Grade 1-5)
 Factors Involved
 Not check Admin History 35%
 System defaults 30%
 Alert issues 30%
 Dual processes 30%
 Integration 4%
Medication Safety Database

24.  Withholding
 New workflow
= not medication specific + 2 steps required + poor visibility
 3 different workarounds trialled…
1. Medicine charted + Administration Alert
2. Medicine ceased + Prescribing Alert
3. Medicine Blocked + Prescribing Alert
Medication Safety Database

25.  Withholding
1. Medicine charted + Administration Alert
 Alert after patient selection, NOT at Administration
 Added in QUALIFIER (displayed at point of Admin)
 Added in Prescribing ALERT
… worked well with 3 prescribers but  with 48 infrequent prescribers …
Medication Safety Database

26.  Withholding
2. Medicine ceased + Prescribing Alert
… no reported issues but risk of medicines not being restarted …
3. Medicine blocked + Prescribing Alert
 Remains charted but unable to be administered
 Flagged on “Overdue Meds” screen (Nurse)
…Not automatically flagged on “Patient Summary” screen (Dr rounds)…
Medication Safety Database

27.  Withholding
 Actions
 Training scenarios
 Education Campaign
 Enhancement Vendor / NeMP
 Preventing roll out to surgery
Medication Safety Database

28.  Wrong start date/time Transcribing
 New workflow = Defaults to start medicine at NEXT available
dosing time
Medication Safety Database

29.  Wrong start date/time
 Action
 Training Dr scenarios
 Educate
 Nurses about doctor workflow, especially defaults
 Pharmacists focus on timing issues for new admissions
Medication Safety Database

30.  Nurse education about prescriber defaults
Medication Safety Database

31.  Strength / Dose mismatch
 New workflow = Prescription includes strength
Medication Safety Database

32.  Strength / Dose mismatch
 Action
 Training scenarios
 Education
 Doctors about strength /dose display in Admin screens
 Campaign for recommended workflows
Medication Safety Database

33.  Strength / Dose mismatch
 Action
 Nurse Workflow Education
 Select medicines from Pyxis in “Administration” screen
 CHECK medicines in “Confirmation” screen (reads like a sentence)
Medication Safety Database

34.  Strength / Dose mismatch
 Action
 Doctor Workflow Education
 If dose expected to change a lot
chart without strength
 For other dose changes, where-ever possible
 “cease” medicine and start new strength
(rather than editing old strength)
Medication Safety Database

35.  Strength / Dose mismatch
 Action
 Enhancement Vendor / NeMP
 Delivered 8.1.1
 Prompt Doctor on editing dose to select more appropriate strength if exists
 Removed strength from left hand side of Nurse “Administration” screen
Medication Safety Database

36.  Not checking Administration History
 New workflow =
 Separate screen & extra mouse clicks
 Not visible at time of Administration
 Action
 Simplification of 7 steps into 3
= llergies, lerts, dmin History (in DRUG ROOM) +
= Selection, Retrieval, Checking (in DRUG ROOM) +
= (at BEDSIDE)
Education Campaign
Medication Safety Database

37.  Not checking Administration History
 Action
 Enhancement
 Last dose administered viewable in Administration screens
 Delivered v8.1.1
Medication Safety Database

38.  Lessons learned
 Compliance poor
 with workarounds when > 1 step
 when > 1 extra mouse click
 Professions need to understand each others workflow
 Users need to be familiar with new types of errors
 There is always another way … you just need to find it
Medication Safety Database

39.  Pharmacist Interventions (Epiphany) Grade 1-3
 Pre 2 years vs Post 1 year
 All n = 14959
 Pilot Ward n = 941 (6.3%)
 MedChart Involved n = 81 (21.5%)
 Sub-analysis
 Place in Medication Use process
 Phase in Patients Admission
 Event Severity
 Type of Event
 Medicines involved
Pharmacist ‘Error’ Interventions

40.  Event Severity 
 Place in the Medication Use Process
  Transcribing
 Type
  Illegal/Illegible/Incomplete
  Wrong Drug Regimen
  Wrong Dose Regimen
  Duplicate Therapy
Pharmacist ‘Error’ Interventions

41.   Wrong Drug
 New workflow = Selection of medicines from list of
forms & strengths
Pharmacist ‘Error’ Interventions

42.   Wrong Drug
 Action
 Training
 Screen shots of common mistakes
 Importance of checking full screen
Pharmacist ‘Error’ Interventions

43.   Duplicate therapy despite DUPLICATION decision support
 Alert Fatigue
 Due to current medicine definition “within past 24hrs”
ie any Edit to a medicine resulted in an Alert
 Action
 Change definition of current medicine to “0 hours”
 Manage risk of “stats” duplication Given = Ceased = No warning
 Change Patient Summary screen to default to past week
 Train Drs to check Patient Summary screen for recently ceased “Stats”
Pharmacist ‘Error’ Interventions

44.  Medicine
  Events for high risk or error prone drugs
 warfarin
 morphine
 oxycodone
 diltiazem
 insulins
 metoprolol
Pharmacist ‘Error’ Interventions

45.  Lessons learned
 Prescribers need support in new prescribing requirements
 Infrequent users forget workarounds
 High risk drugs are complicated to prescribe
 Need to audit & develop new strategies / workflows
 Alert fatigue
 Minimise Alerts where ever possible
 Need new categorisation of errors for ePrescribing
 More efficient recording & data analysis
Pharmacist ‘Error’ Interventions

46.  Process issues
 Transfer
 Paper and electronic chart used concurrently in error
 Integration +++
 WebPAS
 Non-MedChart wards - “Meds Current at Transfer” not easily identified
 Appointments - Pharmacist annotations fall off
Pharmacist Prescriber Advice
Post Go-Live only

47.  Transfer
 Actions
 Training
 “Spot the 7 errors”
Pharmacist Prescriber Advice
Post Go-Live only

48. Sample Chart

49.  Actions
 Training
 Pharmacists trained in areas problematic for Doctors/Nurses
 Enhancements +++
 Ability to print chart as at transfer
 Ability to electronically re-chart once transferred back
 Pharmacist annotations at transfer
 ADT messages not recognised by MedChart
Pharmacist Prescriber Advice
Post Go-Live only

50.  Lessons learned
 Easier to train small, stable group in workarounds
 Pharmacists backstop for Multi-step processes
 Withholding,
 Alerts,
 Qualifiers,
 Duration
 Integration a work in progress
 Multiple issues at transfer
 Dual systems increase risk of errors
Pharmacist Prescriber Advice
Post Go-Live only

51.  Complex
 CONTEXT is everything
 HOW is as important as WHAT
What we found out…

52. What we found out…
…the VALUE PROPOSITION…
...Will need to learn to do things differently,
but there will be benefit in return…

53.  ….You don’t know what you don’t know…
 Environment & product continually changes
Key Lessons

54.  needs to be ongoing & intensive
 Engagement wanes
 High user turnover
 Infrequent users struggle with workarounds
 Regular users don’t see the need for training updates
Key Lessons

55.  Constantly review
 Educate professions about each others workflows
 Educate about new types of errors
 HOW IS MORE IMPORTANT than what
Key Lessons

56.  To be expected, but..
 Will be modified by staff & lead to unintended consequences
 Some workarounds are safer than others
 Need to be identified
 Constant challenge
…..
Key Lessons

57.  Maintaining End User Engagement
 Withholding
 Dual systems / Transfer
 to understand context-related unintended consequences but then…
Key Lessons

58.  Vendor
 Talk different language so define problems / solutions clearly
 Clarify, re-clarify & re-visit
 Other DHBs valuable resource
 Liase regularly & re-visit
 Site visits invaluable
Key Lessons

59.  Sites / Wards have different needs
 Flexible
 Configurable options
 Site collaboration
 Process needs to be supported Nationally
Key Lessons

60. Final Message

61. Contact
Tracey.Watson@tdhb.org.nz

62. Table 1 MedChart Associated Events & Issues Identified at TDHB
Type Description Medication
Incorrect
Start Date/Time
 Regularly” scripts default to todays date, but not due till later in the month
 Start time defaults to next available due dose & was not edited
Incorrect Timing
 Medicines (such as Madopar) prescribed twice daily at 8am/8pm when
should be tailored
 Frequencies have pre-specified default times which may not be appropriate
for certain medicines, however a Dr would not previously had to specify
exact time . eg three times daily (= 8am, Noon, 1800) for medicines that
need to be taken on an empty stomach
 Medicines prescribed at mealtimes that should be on an empty stomach
 Medicines prescribed (via protocols) apart from meals that should be with
meals
 Eye drops charted hourly and need qualifier to say “during waking hours”
Incorrect Frequency  Frequency defaults to ‘once daily’ and was not edited
Frequency &
Administration times
out of sync
 Admin times can be edited by nursing /pharmacy staff, but this may not
match the prescribed frequency (which can only be changed by prescriber)
eg “in the morning at 1800”
Duration issues
 Once duration complete, script ceases and in error may not be continued (or
have dose review) when should be
 Prescribers do not want script to “fall off” so put no duration = overtreatment
and potential resistance
 Editing script, duration defaults to original duration and get overtreatment
and potential resistance
Prednisone

63. Table 1 MedChart Associated Events & Issues Identified at TDHB
Type Description Medication
Incorrect Medicine  drug database categorisation of medicine contributed to confusion Hep saline
Incorrect
Strength of medicine
 Dr would previously have had to chart dose only (not strength), but now
has to chose down to strength, and when editing dose downwards, the
strength should have been changed also
 incorrect medicine strength & for what on stock (dose charted in mL)
Enoxaparin
Methotrexate
Morphine
Incorrect
Form or Formulation
 Dr would not have had the choice between the 2 different preparations and
choose the wrong one
eg MDI vs DPI,
Capsules vs Dispersible Tablets,
Immediate Release vs Slow Release,
Otrivine Menthol Nasal Spray vs Otrivine Nasal Spray
Brand issues
 Cannot chart by brand unless you know the brand name
eg insulin should be charted by brand, but if search by insulin, you do not get the
Penmix brand option (as it does not contain insulin in its description)
 Pharmacist annotations (eg for brand) drop off when patient goes for a clinic
appointment
Route issues  Change to a PEG tube requires re-charting of all medicines
 Vancomycin infusion given orally for C. Diff
Duration issues
 Once duration complete, script ceases and in error may not be continued (or have
dose review) when should be
 Prescribers do not want script to “fall off” so put no duration = overtreatment and
potential resistance
 Editing script, duration defaults to original duration and get overtreatment
Prednisone

64. Table 1 MedChart Associated Events & Issues Identified at TDHB
Type Description Medication
Duplication of Medicines
 Due to alert fatigue
 Due to duplicate warnings not firing for locally added pack
 Due to different script types for the same medicine displaying on different
tabs (regular vs prn vs stat vs variable dose)
 Due to lack of familiarity with how to use variable dose functionality to edit a
dose
Withheld medicines
 Withheld medicine given when no place in the process was set for alert to fire
(ie passive alert only)
 Withheld medicine was given when “at administration” alert was overridden
 Withheld medicine given when “at administration” alert date was set
incorrectly (ie had expired the previous evening)
Minimum Dose Interval
with PRN medicines
 If a dose is given late on the first day (where minimum dose interval is set to 1 day),
the subsequent doses must be given late every day as not available until late
Issues with the process
of using the electronic
chart
 Medicines omitted on transfer from paper chart to MedChart
 Paper chart & electronic chart being used concurrently
 Resupply, Source information and Administration comments fall off the electronic
chart when a patient goes for an appointment

65. ADMISSION TO HOSPITAL DISCHARGE FROM HOSPITAL
Key Messages Key Messages
Medicine and allergy
information from:
• Patient (+ family,
caregivers)
• GP/specialist
• Community
pharmacy
• Rest homes
• Other hospitals
• Ambulance
Allergy Warning + ADR
▪ Input by
pharmacists
▪ 3+ sources used
▪ Discrepancies
listed as
unintentional /
intentional
Medicine and allergy
information to:
Dx summary
(inc DMCS)
Dx scripts
DMCS
Yellow
cards
Patient info leaflets
Patient
Community
pharmacy
Rest homes
Other
hospitals
Discrepancies must be resolved by a doctor within 24 hours of arriving in ED
Patients own medicines into “green bag”
DMCS = discharge medicines changes summary
(Automated Drug Distribution
System)

66.  Pyxis “batching”
 Retrieve ≥ 1 patient at a timeDRUG ROOM
 Administer 1 patient at a time BEDSIDE
…but only 1 Administration step in MedChart
 How did other sites manage time delay between Retrieval &
Administration?
 National workshop
 Process mapping
 Retrieval annotated on paper chart in drug room as a separate ste
TDHB

67.  Regular scripts defaulting to todays date
 New workflow = Dr to specify start date/time rather than just frequency
 Actions
 Education of Nurse in Doctor workflow & new types of errors
 Training scenarios
 Enhancement (blank default)
 Delivered 8.1.1
Pharmacist ‘Contribution’ Interventions

68.  Medication Safety Database (Grade 1-5)
 Place in Process sub-analysis by Type
 Prescribing
 Extra dose (withholding) 25%
 Duplication 25%
 Wrong Drug (strength /dose mismatch) 25%
 Omission 25%
 Transcribing
 Extra dose (wrong start date) 75%
 Omission 25%
Medication Safety Database

69.  Medication Safety Database (Grade 1-5)
 Place in Process sub-analysis by Type
 Administration
 Extra dose
 withholding 44%
 wrong start date 22%
 other 6%
 Wrong dose (strength) 11%
 Wrong time 11%
 Missed dose 6%
Medication Safety Database

70.  Warfarin new workflow
 Medicines arranged in “tabs” by script type
 Editing dose workflow different from other medicines
 Had to select brand (incorrect default)
Pharmacist ‘Error’ Interventions

71.  Action
 Warfarin
 Rules to alert infrequent prescribers to unusual workflow
 Removal of “ALL” tab
 Enhancement
 Change default configuration to brand “unspecified”
Pharmacist ‘Error’ Interventions

72.  Pharmacist Contributions (Epiphany) Grade 1-3
 Pre 2 years vs Post 1 year
 All n = 6061
 Pilot Ward n = 919 (15.2%)
 MedChart Involved n = 26 (9.8%)
Pharmacist ‘Contribution’ Interventions

73.   Administration & Formulation Advice
 Frequency & Administration times out of sync
 Default frequency morning = 8am
 Frequencies have pre-specified default times
 Editing of Administration times by nursing staff
 Regularly scripts
 default to todays date
 Formulations
 Dispersible vs normal, DPI vs MDI
Pharmacist ‘Contribution’ Interventions

74.   Administration & Formulation Advice
 Frequency & Administration times out of sync
 New workflow = Dr to specify administration times ; frequency defaults
 Actions
 Rules to warn when Administration times need to differ from defaults
 Change configuration “mane 08:00” to “od 08:00”
 Training scenarios
 Education re: limitations for Nurse being able to “edit administration
times”
Pharmacist ‘Contribution’ Interventions

75.  Lessons learned
 Nurses need to understand Drs new workflow (eg defaults) &
potential for new types of errors
 Change in work responsibilities created tensions
 Dr now needs to think about nursing workflow (Admin times)
 Education of Drs about nursing workflow
Pharmacist ‘Contribution’ Interventions

76.  Incorrect strength for ward stock
 Morphine oral 2mg/ml prescribed as first choice on list
 Dose displays as mL on Administration screens
 BUT only 10mg/mL held on ward stock (2mg/mL Paeds only) & on Quicklist
 Action
 Change 2mg/mL to NON-FORMULARY
to guide prescriber to select 10mg/mL
Pharmacist Prescriber Advice
Post Go-Live only

77.  Medication Issues
 Incorrect strength for edited dose
 Incorrect strength for ward stock
 Dose edited but not qualifier
 Route issues
 High frequency medicines
 Minimum dose interval for PRN medicines
 If dose given late on first day, subsequent days doses can’t be
started till late
Pharmacist Prescriber AdvicePost Go-Live only

78. Medication Errors