Reviews


While BCMA systems can facilitate appropriate and safe medication use, healthcare professionals have developed deviations, called violations or ‘workarounds’, that occur because of workflow or system designs. Koppel et al.,11


who extensively examined violations using barcode systems, identified that they fall into three broad categories: omission of the process steps (which includes scanning barcodes from discarded medication packages or not scanning medications when barcodes are missing or damaged); steps performed out of sequence (which includes the clinician documenting the medication order chart before the patient has consumed the medication); and unauthorized process steps (which includes the clinician disabling audio alarms on the device).


In a recent before-and-after, quasi-experimental study examining the efficacy of a BCMA system, rates of medication errors occurring in administration and transcription were examined.12


sign and laboratory data. Similarly, Rothschild and colleagues14 examined the effect of realtime decision support provided by smart pumps compared with no decision support. Rates for serious medication errors did not differ between the control and intervention periods. Most significantly, a bypass rate of 25 % was made with the medication library.


Computerized Provider Order Entry In total,


14,041 medication administrations and 3,082 order transcriptions were reviewed. Observers noted 776 (11.5 %) non-timing errors of medication administration in settings that did not use the BCMA system compared with 495 (6.8 %) non-timing errors in settings that did use it (p<0.001). The rate of potential adverse drug events (other than those associated with timing errors) fell from 3.1 % without the use of the BMCA system to 1.6 % with its use (p<0.001). The rate of potential adverse drug events associated with timing errors, which were classified as possibly harmful, did not change significantly. Transcription errors occurred at a rate of 6.1 % in settings that did not use the BMCA system, but were completely abolished in settings that did use it. Based on this comprehensive study, it is apparent that BCMA systems are an important intervention for promoting appropriate and safe medication use.


Intravenous Pump Technology


Intravenous pump technology involves infusion pumps with decision support, which are alternatively known as ‘smart pumps.’ Using barcode programming, clinicians can be provided with safeguards for proper dosing, volume, and vehicle of fluid. Protocols with dose ranges can be pre-set in the pump to detect medication overdose.


Smart pump technology is difficult to accomplish because development of the medication library or decision support system is time-consuming and may not be easy to update. There is also a possible lack of flexibility in the dose ceiling limits provided by the software. In certain clinical situations, such as intensive care or palliative care wards, it can be impractical to impose limits because medications may not have an established therapeutic maximum level. Intravenous opiates fall into this category. Further advances in smart pump technology involve extending its capability to monitor bolus doses, and corroborating infusion information with laboratory and vital sign data.


Extensive research has been conducted on the use of smart pumps, especially in the intensive care environment. Using a retrospective design, Nuckols et al.13


examined the medical records of patients before


and after conventional intravenous pumps were replaced by smart pumps. No changes were found in the incidence of preventable intravenous adverse drug events between the two periods. Reasons mentioned for lack of benefit following the introduction of smart pumps were their inability to address medication boluses, the presence of wide dosage ranges for certain patients, and the lack of integration with vital


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Past research has shown that the use of a CPOE system without clinical decision support can actually increase the rate of medication errors,15 leading to prompts that CPOE systems should be implemented with clinical decision support systems. Wolfstadt and colleagues16


conducted


a systematic review to determine the efficacy of CPOE and clinical decision support systems on the rate of adverse drug events. They found that, out of 10 studies identified, five showed a statistically significant reduction in adverse drug events, four did not reach statistical significance but showed trends towards reduced adverse drug events, and one reported no effect.


Telehealth Technology


Telehealth technology involves the delivery of health-related services using telecommunication facilities such as robotic technology and videoconferencing. Individuals participating in telehealth activities could include patients, family members, and clinicians. It is particularly useful for individuals who are situated in rural or remote environments.


A key driver for effective use of telehealth technology is the need for good communication between healthcare team members. To achieve the goals of telehealth, it is crucial that healthcare professionals of different disciplines are fully aware of each other’s roles and activities in relation to the care of particular patients. Little work has been undertaken to determine the efficacy of telehealth technology in facilitating appropriate and safe medication use. However, correct decision-making about thrombolysis treatment options has been found


iHEALTH CONNECTIONS


CPOE is the process of directly entering patients’ medication orders electronically onto a computer network rather than on a paper chart. Data relating to clinical laboratory and radiology tests or procedures can also be entered onto the computer. While the use of a CPOE system can help reduce errors associated with poor handwriting or transcription, the process is greatly facilitated by adding a clinical decision support system. The system then transmits the order to the appropriate department, or individuals, so it can be carried out. A clinical decision support system can check patients for allergies, drug interactions, duplicate therapies, dose delivery, organ dysfunction, paediatric and geriatric issues, contraindications for use, and pregnancy concerns.


There are a number of potential issues that need to be resolved when using CPOE. CPOE systems need to be integrated into existing electronic systems situated in a particular hospital, and current systems also have to be upgraded to support the implementation of CPOE. On a related issue, CPOE may require extensive, on-site customization prior to deployment to integrate with the workflow processes of a hospital. For maximum efficiency and effectiveness, the CPOE and pharmacy- based computer system should be networked to enable communication between the prescriber and pharmacist. Thus, if the prescriber bypasses a warning, the pharmacist can identify it and intervene if necessary.


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