1. Williams, Cynthia T. MSN, MBA, RN, FACHE

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Medication management targets stages in which errors occur, step by step.


It's been 4 years since the first of two Institute of Medicine (IOM) reports on medical errors put patient safety issues front and center before public and private policy makers.1 The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued its first National Patient Safety Goals and requirements in 2002, with more stringent requirements expected in the near future. When coupled with board-level directives, the pressure is on for hospitals to adopt an automated medication management strategy to address patient safety.


The approach adopted by Alabama's St. Vincent's Hospital in 2001 addresses the IOM concerns and positions the facility well for future regulatory requirements. Medication management is one of five clinical information technology (IT) projects currently underway at the facility, each part of an IT roadmap first developed in 1991. At center is a vast clinical data repository that close to 300 staff members rely on daily.



At St. Vincent's, providers can check every patient test, order, and procedure via an electronic results viewer, accessible from wireless tablets and approximately 1,500 personal computers (PCs) deployed throughout patient rooms and nursing stations across the six-building hospital campus. In patient rooms, medical devices such as blood pressure monitors are connected to each bedside PC, so vital sign information doesn't have to be reentered. Through dual-monitor computers at each nursing station, providers can review digital radiographic images alongside current clinical data, such as medication orders, patient allergies, laboratory results, and other clinical observations.


Prescribers have secure "anytime, anywhere" Internet access to patient charts for electronic review and signature from remote locations. Nurses also use a point-of-care clinical documentation system designed to map closely to their workflow. It features an interface that adapts to each nursing specialty, enabling faster charting. In addition, a rules-based clinical alerts system monitors all clinical data and proactively notifies caregivers of any situation that needs immediate attention or that could negatively affect patient care.



Numbers vary by study, but generally show that 56% of potential medication errors occur during the ordering process, compared with 10% during dispensing and 34% during administration. Although the order and dispensing phases are critical to medication error prevention, 48% of errors are intercepted there through normal processes and only 2% are intercepted by the time the medication reaches the administration phase.2 With these data in mind, St. Vincent's staff chose to start with dispensing in the pharmacy, then move to administration on the floor, then tackle prescribing and transcribing.


Staff began by identifying the primary departmental stakeholders (in this case, nursing and pharmacy) and defining their objectives. For nursing, the major objectives were to free up time for direct patient care and improve documentation quality. The pharmacy wanted an automated order entry system that would improve patient safety; enable its staff members to be more clinically involved; and improve collaborations with nurses, prescribers, and laboratory staff.


First, facility personnel implemented an advanced pharmacy information system with efficient electronic order entry and advanced clinical screening that checks for drug/drug, drug/allergy, and therapeutic class duplications. They also deployed automated dispensing cabinets, featuring locked, sensed pockets that prevent clinician access to nonprescribed medications based on order information received from the pharmacy system.


When an order is completed in the new pharmacy system, it passes electronically to the automated cabinets and to a bedside workstation that nurses must log into and use during medication administration. A scanner attached to the device captures a two-way bar code match between the patient's wristband and the unit-dose medication packet. The integrated system confirms the "five rights" of medication safety. If all elements are correct, the nurse administers the medication, which is charted in the medication administration record (MAR) and immediately integrated with the patient's other clinical documentation.



The goal of any medication safety initiative is to prevent errors-not to assign blame. By upgrading the pharmacy system and changing departmental workflow, clinicians can better ensure that medications are administered during the right time frame, a common contributor to potential medication errors. In addition, pharmacists are more involved at the beginning of the medication process, establishing starting times for medications in consultation with nursing. With better scheduling information, pharmacy technicians now stock cabinets to ensure medications and supplies are on the floors when and where needed. Pharmacy also initiates and reviews the MAR, eliminating duplication. As a result, nursing has an accurate MAR that's always up to date.


Automation has also allowed St. Vincent's staff to uncover issues regarding drug dosage delivery to the floor and in some cases, has prompted changes to how medications are packaged. Clinicians have also been able to identify the need for education on some new or higher-risk drugs.



Computerized provider order entry (CPOE) virtually eliminates errors of commission (prescribing the wrong medication or the wrong dose), omission (failing to prescribe a needed medication), and transcription (prescription misinterpretation). Experts in preventing medication errors, such as the Washington, D.C.-based Leapfrog Group, favor systems that provide multitiered decision support during the prescription process, incorporating coded medications and allergies, as well as standardized, formulary-compliant order sets.3


This technology displays clinically relevant information about a patient's condition, along with evidence-based guidelines and treatment protocols. Moreover, these systems proactively alert clinicians to time-sensitive information regarding critical patient laboratory and medication values. For example, when a prescriber orders an aminoglycoside through CPOE, the system checks the patient's creatinine lab values. If the value is normal, no alert is generated. If the value is elevated, the system sends an alert to the prescriber, advising of the lab value and the ordered medication.


Prescriber resistance to CPOE can prove challenging despite the system's clear benefits. To win user acceptance, St. Vincent's planners involved prescribers in every step of the process: vendor selection, content, workflow, and devices. A prescriber liaison/system analyst works one-on-one with clinicians to ensure efficiency of the workflow change. And because the facility's medical staff have already experienced the benefits of previous IT initiatives, it has willingly participated in CPOE development and implementation.



With this approach, St. Vincent's is well on its way to achieving a closed-loop medication management system. If you're just formulating a patient safety or compliance strategy, first consider upgrading pharmacy capabilities to an expert ordering system integrated with automated cabinets and deploying bar code scanners at the bedside for medication administration. In St. Vincent's case, the greater capital outlay required for CPOE-despite its value-strongly influenced the staff's decision to begin in the pharmacy and then move to medication administration before undertaking CPOE. You may also want to consider investing in another proven technology: a robot that responds to electronic medication orders from the pharmacy system and automates the stocking and dispensing of barcoded unit-dose medications.


Whether you opt for a limited medication management strategy or a fully closed loop, the same critical success factors apply. Your plan must reflect your organization's overall strategy and objectives. Project leaders must involve departmental stakeholders early on. Finally, a pervasive focus on improved patient safety and high-quality outcomes must drive each stage of the process, making healthcare truly safer-step by step.




1. Committee on Quality of Health Care in America, Institute of Medicine. To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 1999 and 2001. [Context Link]


2. Leape L, et al. Systems analysis of adverse drug events. J Am Med Assoc. 1995;274(1):35-43. [Context Link]


3. The Leapfrog Group. Available at: [Context Link]