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A medicine, or a poison, but for the dose

We have all been aware for many years that hospitals in England as in many countries around the world report a growing number of patients who receive the wrong medicine, the wrong dose, at the wrong time or via the wrong route. There are also a cohort of patients who receive medicines late or who miss doses all together. We are also aware of the role that technology can play in reducing this error rate by bringing greater rigour to the dispensing and administration processes in order to significantly increase patient safety and the overall quality of clinical care.

A typical workflow would begin with the clinician generating an electronic prescription, which is then electronically checked or verified by a pharmacist against a pharmaceutical database and the patient’s electronic medical record. Technology enabled dispensing then allows the nurse at the bedside to use technology again to identify themselves, the patient, the medicine and the correct dose, before safely administering the medicine to the patient. This is a practice that is already well established in many hospitals around the world. However, deploying electronic prescribing and medicines administration systems in isolation is not the answer and should be avoided.

The approach to safely prescribing, dispensing and administering medicine in hospitals must be considered in context and aligned with other clinical systems in order to obtain the desired effect. A prescribing intention can be often enhanced when a known laboratory value is made available to the doctor in a seamless and timely manner. Doctors prescribing a blood thinner would want to be aware of the rate at which the blood is currently clotting. The prescriber would equally need to be aware of the condition of the kidneys in the presence of medicines known to affect renal function.

Utlilising algorithms

The patient is a valuable source of information to the prescriber. Electronic Personal Health Records will often contain information that relate to previous drug to drug interactions, allergies, drug / food interactions and patient preference. The dose of a medicine is often influenced by the weight and age of the patient. The clinician would not want to unintentionally give an adult dose of a medicine to a child. This can be avoided when the prescriber is automatically made aware of the patient’s date of birth and body mass index (BMI). It can be even more effective when the date of birth and BMI automatically calculate the dose.

There are also some clever computer algorithms, which tend to work better when all the clinical data is in the same place. The sepsis early warning system for example may use a number of clinical parameters to determine if a patient may be at risk of developing sepsis. This could involve checking blood pressure, heart rate, oxygen saturation and respiration rate. The clinician may then decide on further interventions such as monitoring the level of oxygen and carbon dioxide in arterial blood, checking for the presence of bacteria in the blood or adjusting the antibiotic prescription. Electronic Clinical Decision Support can add much more value when the computer algorithm has access to all the information it requires rather than just a subset.

The case being made here is for the prescribing and administering of medicine to be within the patient’s electronic medical record and not bolted onto the side or indeed in an isolated system that is unable to communicate with other valuable sources of clinical data. Electronic prescribing is a team sport in that it needs the support of other data sources, other health professionals and also the patient in order to be truly effective.

So whilst I am heartened by and have full support for the latest government initiative to improve hospital safety. I sincerely hope that those with responsibility for procuring ePMA type functionality have regard for all the other things that this process requires in order to improve medicine safety.

The unintended consequence of isolating the prescribing and medicine administration processes from the rest of the clinical data is that we actually increase risk to patient welfare rather than reduce it.  

John Rayner is Regional Director – Europe. Healthcare Advisory Services Group – HIMSS Analytics

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