E-medication management not a ‘panacea’: study

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Organisations must remain vigilant to the risk of new errors following the roll-out of eMM systems, say Melbourne medication safety pharmacists

While electronic medication management systems (eMMS) have been demonstrated to improve medication safety by reducing medication errors, it is also recognised that they cause new types of errors.

These include incorrect medication dose or form selected from drop-down menus, and duplicate orders for the same medication due to fragmented screen design.

Sometimes such errors may have a fatal outcome.

For example in June 2015, a patient died after being given the wrong medication at a Sydney hospital just one month after the institution had rolled out a new electronic medical record system, which provided the ability for ‘one touch’ prescribing.

Acting State Coroner O’Sullivan found in an inquest this year that while the electronic system did not cause Mr Lau’s death, “the initial prescription error was made easier due to a function of … great utility – the ability to open and close different patient records from a single terminal.

“Prior to the introduction of electronic medical records, it was much more difficult to charge medication on the wrong patient file.”

Three experienced medication safety pharmacists based in Melbourne conducted a retrospective audit of reported medication incidents from incident reporting databases across eight Victorian hospitals with eMMS, between May and July 2014.

There were 5826 medication-related incidents reported, according to the study published in the Australian Health Review.

During the three-month period, 93 (47 prescribing errors, 46 administration errors) were identified as new or potentially related to eMMS.

Only one ‘moderate’-level and no ‘severe or death’-level errors were reported, so harm to patients was minimal.

The most commonly reported error types were ‘human factors’ and ‘unfamiliarity or training’ (70%) and ‘cross-encounter or hybrid system errors’ (22%).

“We believe the results of the present study will highlight to organisations the need for ongoing review of system design, refinement of workflow issues, staff education and training and reporting and monitoring of errors,” they write.

“Although eMMS technology removes the opportunity for many medication error types, others may occur more frequently and new error types may emerge.

“[While] the results of the present study suggest the errors reported were of low severity, continuous monitoring of errors is important,” the authors warn.

“Organisations must remain vigilant to the risk of new errors and avoid the assumption that eMMS is the panacea to all medication error issues.

“A system for ongoing review of medication-related errors by medication safety pharmacists and medication safety governance committees is important to detect eMMS issues and opportunities for improvement.”

Read the full study here

Read this AHR study on ‘Going digital: a checklist in preparing for hospital-wide electronic medical record implementation and digital transformation’ here

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