Download Dispensaries: A pharmacist free zone ?’

Andrew Barker
Clinical Director Pharmacy & Medicines Management
[email protected]
The DBH experience with the JAC
e-prescribing module
Electronic Prescribing
• Description of the system
• Why did we want electronic prescribing?
• The DBH Project
•
•
•
•
History
Where we are now?
What have we learned?
What next?
Hospital electronic prescribing
and administration recording etc.
PAS
WARDS
PHARMACY
OUT-PATIENTS
‘HOSPITAL
EPR’
National
spine
The System
•
We are using JAC’s prescribing software which
incorporates the Multilex Drug Data File from
First DataBank Europe to provide decision
support warnings for allergies, interactions and
duplicate therapy.
•
In addition to prescribing, the system also
provides ‘real time’ electronic recording of
medicines administration, clinical pharmacy and
medicines management activities.
•
It is fully integrated with Pharmacy stock control
to allow the automated ordering of medicines.
Why – to manage clinical risk
• 5 - 6 % of hospital admissions result in an adverse
event resulting from the use of medicines
(Vincent et al, BMJ 2001 & Bates et al JAMA 1995)
• Outcomes (Bates et al JAMA 1995)
• Fatal
1%
• Life threatening
12%
Why – to manage clinical risk
• Overall 28% of these adverse events are
preventable
• 42% of those classified as fatal, life threatening or
serious were preventable
• The following were the main contributory factors
to preventable adverse events
• Prescribing errors
62%
• Administration errors 34%
• Dispensing errors
4%
Why – to manage clinical risk
• Prescribing errors occur at a rate of 3 - 4 per 1000
items prescribed (Leaser et al JAMA 1990 &1997)
• Common causal factors were:
• Lack of knowledge or application of knowledge
about the medicine
30.0%
about the patient
29.2%
• Calculations
17.5%
• Nomenclature
23.4%
Why – to manage clinical risk
Introduction of electronic prescribing,
and associated on-line decision support,
can reduce serious adverse drug events by
55%
From 10.7 to 4.86 per 1000 patient days (Bates et al JAMA 1988)
Why - other benefits
• Electronic patient records
• Improved communication with primary care
• Improved operational efficiency
The DBH JAC Project
• Initial single ward evaluation (2002 to 2003)
• Pilot implementation Montagu Hospital (2003 to 2005)
• 2 acute medical wards & 2 rehabilitation wards
• Decision support was added to the system in October 2004
• First Operational Implementation Bassetlaw
Hospital (November 2005 to 2007)
• Medical Unit (6 wards including Acute Admissions Unit and
CCU)
• Full Trust Implementation agreed 2007/8
The DBH JAC Project
• Current position
• Live on all three sites
• Full system on 20 wards
– 11 Medical (including CCU, Renal, Acute & Rehab.)
– 8 surgical (including Gen Surg, Ortho & Gynae)
• Discharge only on 12 wards
• May 2005
• 200 doctors prescribed 24,048 Medicines for 1,537
patients
• 329 nurses recorded 144,290 administrations
What have we learned?
How does electronic prescribing reduce
clinical risk?
• Unambiguous prescriptions & administration
records
How does electronic prescribing
reduce clinical risk?
• Unambiguous prescriptions & administration
records
• Decision support
– Product selection
Formulary, protocols, (pathways,) etc.
–
–
–
–
–
Route, dose and frequency defaulting
Allergy checking
Drug interactions
Therapeutic duplication
(Max/min dose checking)
Audit of Decision Support Warnings
2 month audit on two acute medical wards
Patients with electronic prescriptions
Individual lines prescribed
Decision support warnings issued
– Drug interactions:
– Allergies
– Duplicate therapy:
1,081
33
1,405
387
7,106
2,549
Outcomes of Warnings
Audit of Decision Support Warnings
Outcomes of warnings:
• Heeded
• Proceed
–Alternative route/PRN product
–Intended duplication
–Benefit outweighs risk
–Patient already stabilised on drugs
–Not clinically significant
9.1%
4.3%
45.2%
14.9%
20.1%
6.4%
90.9%
Audit of Decision Support Warnings
• Further analysis: repeated warnings
• Of 2,549 warnings issued 1,582 (62.1%)
were repeated warnings
• If repeated warnings are excluded then in
the region of 20% first warnings were
heeded
Audit of Decision Support Warnings
• The bottom line
• On 74 occasions (1 in 97 orders) the
prescriber did not complete their initial
prescribing intention
Patient Outcomes ?
Introduction of electronic prescribing,
and associated on-line decision support,
can reduce serious adverse drug events by
55%
From 10.7 to 4.86 per 1,000 patient days
(Bates et al JAMA 1998)
Audit to determine the effect of electronic
prescribing and decision support on potential
adverse drug events
(Barker & Kay, Hospital pharmacist; 207, 14: 225)
Independent review of in-patient prescriptions on two
acute medical wards before and after the introduction of
electronic prescribing with decision support
Patients
Items
prescribed
Before
94
702
After
95
706
RESULTS
Potential ADE per 100 items prescribed before
and after the introduction of electronic
prescribing
12
10
8
6
4
2
0
Before
After
RESULTS
Potential ADE by severity per 100 items prescribed
before and after the introduction of electronic
prescribing
10
8
Before
6
After
4
2
0
Minor
Moderate
Major
RESULTS
Potential ADE per 100 items prescribed before
and after the introduction of electronic
prescribing by cause of potential ADE
Monitoring required
Administration
Medication Selection
Additional Therapy
0
1
Before
2
After
3
4
RESULTS
Potential ADE per 100 items prescribed before and
after the introduction of electronic prescribing by
cause of potential ADE
Medication
withheld
-100%
0
1
2
Before
After
3
4
RESULTS
Potential ADE per 100 items prescribed before and
after the introduction of electronic prescribing by
cause of potential ADE
Dose Selection
-88%
0
1
2
Before
After
3
4
RESULTS
Potential ADE per 100 items prescribed before and
after the introduction of electronic prescribing by
cause of potential ADE
Unnecessary
Therapy
-55%
0
1
2
Before
After
3
4
RESULTS
Potential ADE per 100 items prescribed before and
after the introduction of electronic prescribing by
cause of potential ADE
Medication
Selection
+74%
0
1
2
Before
After
3
4
Other Advantages
• EPR, NHSRS etc
• Could make all medicines use information
(prescribing, dispensing and administration)
available as an electronic record – but not yet
• Improved communication with Primary Care
DISCHARGE LETTER
Date: 18-Jul-2007 @ 11:12
Page 1 of 2
Demographics,
Ward & Consultant
Allergy
etc.status
Patient: MARGUERITE HOLT
NHS No.: 4344829581
Address: 62 WESTMORLAND HOUSE,CUMBERLAND CL,BIRCOTES,DONCASTER S
YOR,DN11 8BY
Ward: C3 WARD
DOB: 20/09/1919
Consultant: Dr M (MM2) Muthiah
Hospital: Bassetlaw General Hospital
Known drug allergies: SALICYLATES
Drug
Discharge
prescription
Dose
Route
Frequency
BUPRENORPHINE MATRIX 35 micrograms
released per hour Patches
1 Patch
TRANSDERM every 72 hours,
AL
FERROUS SULPHATE 200 mg Tablets
200 mg
ORAL
FOLIC ACID 5 mg Tablets
5 mg
ORAL
GABAPENTIN 300 mg Capsules
300 mg
LANSOPRAZOLE 15 mg Capsules
Admission details
Diagnosis
Details of hospital
management
Suggested
further
management
Further
information
followup
OPtofollow
Discharging Doctor
Days
Supply
GP to
continue
28
Yes
THREE times a day,
28
Yes
in the MORNING,
28
Yes
ORAL
THREE times a day,
28
Yes
15 mg
ORAL
in the MORNING,
28
Yes
PARACETAMOL 500 mg Tablets
1000 mg
ORAL
FOUR times a day,
28
Yes
PREDNISOLONE 2.5 mg Enteric Coated
Tablets
2.5 mg
ORAL
in the MORNING,
28
Yes
SOTALOL 80 mg Tablets
80 mg
ORAL
TWICE a day,
28
Yes
,
Pharmacist details
Pharmacy Notes
REPRINT
Hosp. No.: B481068
On ward
*** Please complete in handwriting the controlled drug prescription(s) on the following sheet(s) ***
*** Prescription not verified by hospital pharmacist ***
Pharmacy notes:
Date admitted: 11/07/2007 (Emergency Admission - DIARRHEA)
Date discharged: 17/07/2007
Address discharged to: Home
Diagnoses: DIARRHEA
Relevant aspects of management in hospital
ADMITTED WITH DIARRHEA. INFLAMMATORY MARKERS WERE WITHIN NORMAL LIMITS. TREATED
SYMPTOMATICALLY. STOOL CULTURES WERE NEGATIVE. BEING DISCHARGED AND WILL FOLLOWUP WITH GP.
Further management suggested:
Further information to follow:
No further information to follow
Out-patient appointment arranged:
None
Discharging doctor: DR M ALZOUEBI, SENIOR HOUSE OFFICER
Bleep: 3124
DISCHARGE LETTER
Date: 18-Jul-2007 @ 11:12
Page 1 of 2
Patient:
Hosp. No.:
Address:
NHS No.:
Ward:
DOB:
Hospital:
Consultant:
REPRINT
Known drug allergies: SALICYLATES
Drug
Dose
Route
Frequency
Medication started during admission
Medication started
with reasons
Drug
Reason
Medication discontinued or changed during admission
Drug
Medication changed
or discontinued with
reasons
Reason
,
Pharmacy notes:
Date admitted:
Date discharged:
Address discharged to:
Diagnoses:
Relevant aspects of management in hospital
Further management suggested:
Further information to follow:
Out-patient appointment arranged:
Discharging doctor:
Bleep:
Days
Supply
GP to
continue
Other Advantages
• EPR, ICRS, NHSRS
• Makes all medicines use information (prescribing,
dispensing and administration) available as an
electronic record
• Communication with Primary Care
• Audit
• Massive potential – but not yet fully realised
Operational benefit
• Medical staff
– Compliance with Trust Policy for writing prescriptions from
37% to 96%
– Improvement in accuracy of transcription from inpatient to
discharge prescription from 46% to 93%
Operational benefit
• Nursing staff
–
–
–
–
Work-load prioritisation
Date/time stamps
Medication round times
Compliance with Trust policy on recording administration
from 65% to 100%
• Pharmacy
– work-load prioritisation
– stock control/ordering
– financial information
Other issues
• Cultural issues
•
•
•
•
Doctors
Nurses
Pharmacy staff
Medical records etc.
• Hardware & infrastructure
Peripheral hardware
Other issues
• Cultural issues
•
•
•
•
Doctors
Nurses
Pharmacy staff
Medical records etc.
• Hardware & infrastructure
• Software
Other Issues
• Training
• Clinical Governance
• Validation
• Security
• Resilience
• Finance/affordability
Prescribing
Administration
BLOGGS, JOE
KENT, CLARK
SMITH, JOHN