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Appendix A: Information about “Drugs and patient safety – LOP” for Helse Vest Table of content 1. 2. 3. 4. 5. 6. Background ........................................................................................................................ 3 Objectives and strategic foundation ................................................................................... 3 Solution scenarios .............................................................................................................. 7 key aspects to consider when choosing solution components ............................................ 8 Preparedness solutions and non-conformity management ................................................. 9 Roadmap, LOP 2011-2020 ................................................................................................. 9 Appendix A - Information about LOP Page 2 of 11 1. BACKGROUND The drugs and patient safety project LOP (LOP - Legemiddel Og Pasientsikkerhet) has long-standing history in The Western Norway Regional Health Authority (Helse Vest). The initial project mandate was approved in a meeting of Helse Vest executive officers in March 2008, and the LOP1 report was approved by the same meeting in May 2009. The LOP2 report was similarly approved in December 2009. On the basis of this report, it was decided that certain key areas were to be continued in a new project, LOP3, which in turn was continued in the work of the LOP4 project. The overall objective is to reduce the number of preventable, undesired incidents involving drugs. The LOP-project should also recommend solutions that would provide easy access to data in the medical record, such as vital signs, clinical observations, test results, orders, and data capture from medical devices. The project group was assigned the task of investigating and recommending actions to achieve the overall objectives. The project group comprised more than 40 members. It was an interdisciplinary effort, with representatives from all health trusts, including the hospital pharmacies, Helse Vest IKT AS, and Helse Vest’s user involvement representatives. The project report was completed in June 2011, and several short- and long-term actions have since been started. The solution scenarios are described in chapter three and in then roadmap in chapter six. 2. OBJECTIVES AND STRATEGIC FOUNDATION Helse Vest is to acquire solution(s) for (1) an electronic medical record/chart system that will display, analyse and store clinical information such as vital signs, observations, test results, orders, and automatic data capture from medical devices. The solution should include a computerized provider order entry system (CPOE). The solution should also facilitate preparation, administration and documentation of drug treatment. (2) drugs supply; ordering of drugs for a hospital unit from a hospital pharmacy/supplier, delivery of the drugs (preferably unit dose) to that unit and storage in the unit. The electronic medical record system in request must be user friendly and should provide solutions for integration with existing and future clinical information systems in the organization and also with the requested drug supply system. The future (secondary particularly objective of solution(s) must support integrated patient care, both within Helse Vest and tertiary care) and in interaction with other health service providers, the primary health care services. It must contribute to the overall project reducing the number of preventable, undesired incidents involving drugs. These objectives have been developed into operative targets, as follows: Appendix A - Information about LOP Page 3 of 11 • Solutions should contribute to proper distribution, handling and use of drugs clinical decisions, correct ordering, • Solutions should provide or support clinical decision support systems • Solutions should improve work-flow • Solutions should contribute to better cooperation and coordination (integrated patient care) within and across the health trusts , the regional health authority and the primary health care • Solutions should meet requirements for documentation and reporting. • Solutions should contribute to improved data gathering • Solutions should support interfaces with technical medical equipment such as patient monitors, ventilators, infusion pumps etc. and existing information systems such as laboratory systems, blood-management systems, and EHR information solutions • Solutions should enhance and improve internal audit processes and support validation of equipment and processes • Solutions should be user-friendly • Solutions should be able to facilitate for new technologies and/or procedures LOP objectives: Appendix A - Information about LOP Page 4 of 11 Appendix A - Information about LOP Page 5 of 11 Drugs are substances, pharmaceuticals and solutions assigned for or administered to • prevent (e.g. anticoagulants) • treat (e.g. antibiotics) • alleviate (e.g. analgesics) • detect (e.g. radiocontrast agents) disease, symptoms, pain and/or influence physiological functions. Helse Vest purchased drugs in the amount of NOK 506 million in 2010. Patient safety is protection from avoidable adverse patient events, caused by health care services or lack off health care services. It does not cover injury as a consequence of disease, foreseen complications or consequence of treatment that does not work. (Kunnskapssenteret: Norwegian Knowledge Centre for the Health Services, Sep. 2010). LOP has strong regional foundations, and contributes to objectives as laid down in the Regional Health 2020 Strategy, quality improvement strategy, ICT strategy and the EHR 2020 strategy. Furthermore, the project supports national objectives, which in turn also are regional objectives, defined in • Samhandlingsreformen (The Coordination Reform - regjeringen.no) • Nasjonalt meldingsløft (The Message Exchange Programme) • Pasientsikkerhetskampanjen (The Norwegian patient safety campaign) • eResept (Electronic prescription ) • Medikasjonstjeneste i spesialisthelsetjenesten (the Medication Service for the Specialist Health Care) • Prosjekt Nasjonal Sykehus-FEST (the Administration Support Programme) • Kjernejournal (the National Electronic Health Record Programme) • Nasjonal Helseplan (the National Health Plan)(Nasjonal helseplan 2011 - 2015) • Nasjonal Helseportal (the National Health Portal) • Nasjonal IKT (National ICT) National Hospital Prescription and Several studies have concluded that new measures in the drugs administration area are necessary, • Medication errors in 20 percentage of treatment pathways The Drugs Report (Report no. 18 to the Storting, 2005) • Costs of medication errors estimated at approx. NOK 5 billion per year in Norway The Drugs Report (Report no. 18 to the Storting, 2005) Appendix A - Information about LOP Page 6 of 11 • 27 percentage of all reported injuries involve drug use or drug handling Norwegian Board of Health Supervision (Summary report, 2001-2007) • 610 reports on medication errors over a four-year period at St. Olavs Hospital The Medication Errors for Patients Admitted to Hospital Report (Teigen et al., Journal of the Norwegian Medical Association, no. 13/2009) • 3,770 non-conformance reports involving drugs handling in Helse Vest between 2009 and August 2011 Section for Patient Safety, Bergen Hospital Trust (September 2011) SOLUTION SCENARIOS 3. LOP has opted to evaluate solution scenarios in three main processes: - documentation of and easy access to data in the medical record, such as vital signs, clinical observations, test results, orders, and data capture from medical devices - drugs to patients - drugs supply These processes are described in more detail below, however the overall objective for a future solution is that these main processes are well coordinated. The chart is traditionally defined as a graphic presentation of patient-related information and results along a timeline. The chart is part of the patient’s medical record and is an interdisciplinary presentation of patient progress, containing information about the patient’s health and completed on-going and scheduled treatment. It acts as a channel of communication between doctors and nurses and between various teams and units. The current charts and medical documentation solutions are primarily paper-based, with a few exceptions. LOP recommends that existing paper-based chart solutions are replaced with electronic solution(s) meeting current and future user needs, as well as requirements regarding documentation and reporting. A future electronic charts and medical documentation solution is expected to meet all relevant needs throughout the patient pathway, including any needs related to the drugs to patient process. The drugs to patient process is defined as the process of drugs documentation and handling, from the time the patient becomes the responsibility of the hospital (including prehospital services/ambulance))and until the patient leaves, including support functions pertaining to this process. Furthermore, this process also includes the exchange of information regarding the patient’s medication when he or she is transferred between units/levels of care. The current drugs to patient process are highly complex, involving many different actors and various chart systems (the majority of which are paper-based). The process requires manual registration and transfer of critical information throughout the patient pathway. LOP recommends an electronic solution with standardized processes, facilitating the use Appendix A - Information about LOP Page 7 of 11 of clinical decision support systems. New electronic processes should contribute to integrated care, increased patient safety, increased safety for staff and better documentation procedures. New solutions should also facilitate reports for the use of quality improvement purposes, research and management purposes and the process of submitting reports to central authorities. Quality requirements issued by supervisory authorities etc. should also be met more easily. The drugs supply process is defined as the process of ordering drugs for a hospital unit from a hospital pharmacy/supplier, and delivery of the drugs to that unit. The current drugs supply process is characterized by labour-intensive manual procedures. The main recommendations from LOP are to introduce electronic solutions for ordering and stock management, increase the supply and use of unit-dose drugs, use automated dispensing cabinets for safer storage where suitable, implement ”top-up” pharmacy-managed stock, including expanded process support to contribute to a more efficient supply and proper use of drugs. 4. KEY ASPECTS TO CONSIDER WHEN CHOOSING SOLUTION COMPONENTS The main focus of LOP is the user situation. A critical element for success for any future solution is that the user situation is perceived to be – intuitive – quick – simple – informative – motivating – flexible Throughout the LOP project, user groups have actively participated in designing solution scenarios, describing what needs to be changed. To increase the awareness of opportunities and challenges, the project has carried out study visits. Before deciding on any solutions or suppliers, several reference visits will be carried out. Below is a non-prioritized list of aspects to be considered when choosing solutions: high availability of solutions back-up solutions that automatically take over in the event of errors, scheduled and un-scheduled stops, ensuring uninterrupted access to updated critical information and other services user-friendly interface easy and quick access to information and services compatibility with both mobile and stationary electronic equipment compatibility with workflow processes and patient pathways across professions, functions, organizational units and levels of care to ensure continuity in the flow of information, e.g. about drugs Appendix A - Information about LOP Page 8 of 11 technical solutions applicable to standards for the health sector flexibility in terms of integration with existing solutions and adapting of future needs and requirements technical solutions based on recommendations and guidelines for the health care service, e.g. service-oriented ICT-architecture possibility of clinical decision support, e.g. regarding drug handling and administration possibility of logging changes in information and execution of the various data and processes possibility for solutions for reporting data for analytical purposes possibility of regional solutions, which are flexible enough to handle variations when this is necessary, based on actual differences in treatment and other critical activities PREPAREDNESS SOLUTIONS AND NON-CONFORMITY MANAGEMENT 5. Provisions in the Comprehensive National Health and Social Preparedness Plan require specialist health care services to establish and maintain emergency preparedness plans. The intention behind this plan is to prevent crisis and breakdown of critical functions, and to ensure efficient crisis management and organization of the preparedness plans. ICT is a key element in the hospital infrastructure, and the availability of all ICT services must be secured. Preparedness plans must be implemented in case the ICT-services should no longer be available. Availability is crucial for all solutions, especially for those related to the drugs-to-patient process and charts and medical notes process. Information provided by these solutions is critical for patient safety. Solutions must therefore be secured with back-up solutions that take over; with updated information about patient status and treatment from the instant major service interruptions occur. Solutions must be monitored in such a way that any irregularities are detected and the operator is notified. Whenever possible, solutions must offer automatic back-up solutions in the event of service interruption. ROADMAP, LOP 2011-2020 6. A roadmap has been developed for the 2011-2020 period, see below. This roadmap describes short- and long-term measures, the objectives of the project, and which national measures the LOP project supports. Some short-term measures will be implemented as soon as possible because they add value without new investments or major changes because of expectations or requirements laid down by national authorities Appendix A - Information about LOP Page 9 of 11 At the same time, a procurement process is initiated for future solutions that will meet the project recommendations regarding charts and medical notes, drugs-to-patient and - the drugs-supply processes. This procurement process aims to procure a comprehensive solution, however we must look for solution components for the future, however making sure it is a proven record of the components promised results consider the sequence the solution components should be introduced consider which components each of the hospital trusts unit should have (and in which order they should be introduced) o as it is not given that all units will receive all components of the comprehensive solution o as there could be versions of each individual component, where volume and cost/effect must be considered for each unit pilot all new solution components before introducing them The LOP activities are summarized in the following roadmap: Appendix A - Information about LOP Page 10 of 11 2011-12 • T1: Increase use of unit dose drug packages • T2: Increase use of Top-Up service of drug delivery from pharmacy to drug storage rooms in hospital wards Local and regional solutions • T3: Increase use of pharmaceutical advisory services • T4: Consider introducing a temporary electronic ordering system for drug ordering from hospital ward to pharmacy •T5: Consider carrying forward the use of electronic patient records(EPR`s), currently in use in W estern Norway Regional Health Authority(EPR) • T6: Piloting and introduce a shortterm solution for ePrescription • T7: Introduce short-time solutions for improving medication history taking, medication reconciliation and medication information for patient coming from /returning to primary care 2013-17 2018-20 • T9: Piloting and introduce electronic drug stocking management and ordering system for hospital wards • Continue • T10: Piloting and implement Automated dispensing cabinet for drugs in hospital wards T10, T11, T12, • T11: Piloting and implement electronic system, supporting prescribing, administration and dispensing of medication(EMR), electronic patient identification and electronic information transfer to/communication with primary care T13 and T14 • High achievement of gains and benefits • T12: Piloting and implement electronic support system for all other use of medical charts and notes • T13: Piloting and implement long-term solution for e-Prescription • Continue T1, T2 and T3, T4 continues in T9, T5 in T11/T12 T6 in T13 and T7 in T11 Escalation of gains and benefits • T8: Prepare and implement procurement-process Partial achievement of gains and benefits: • Fewer avoidable, medication errors/drug adverse events • Improved patient safety and quality • Improved patient pathway and interaction • Reduced costs related to use and stockholding of drugs and of personnel • Improved and easier follow up of regulatory demands- and programs • Improved and easier reports for change management and research • Improved patient satisfaction and employees satisfaction • Improved system support for a safe and good working environment Gains / Benefits Appendix A - Information about LOP LOP T3, T4, T5, National Quality indicators National patient record Patient portal Patient Safety Campaign The Coordination Reform National e-communication in health and social service Electronic registry of drug information for prescribing and expeditions/dispensing (FEST) e-Prescription Medication IT services Patient Safety Campaign The Coordination Reform National e-communication in health and social service Electronic registry of drug information for prescribing and expeditions/dispensing (FEST) e-Prescription Medication IT services National programs Page 11 of 11