Clinical Electronic Systems in Medication Administration Technology

Introduction: Medication Safety and Technology

In 2000, following a large wave of accidental deaths (approximately two million) that occurred nationwide, the Department of Health Services (DHS) surveyed hospitals in California regarding the relationship between patient safety and technology, and which technological systems they planned to procure by 2005. This review describes and evaluates five clinical electronic systems that correlate with the process of medication administration technology: Computerized Physician Order Entry (CPOE), Electronic Medication Administration Records (eMAR), bar-coding technology, Automated Dispensing Cabinets (ADC), and Smart IV Pumps.

Computerized Physician Order Entry (CPOE)

Forty-six percent of the hospitals surveyed rated the Computerized Physician Order Entry (CPOE) as their preferred technological system, since it helps the prescribing clinician enter the medication order directly into the system (Spurlock et al., 2003). The CPOE can also instantly detect errors in prescriptions and employs various levels of decision support to flag situations that could lead to prescribing errors, such as duplicate or incorrect doses. Equally important, the CPOE can prevent certain types of errors — including allergy conflicts, dosing parameter violations, and weight-, age-, or renal-function-related issues — from being entered into the prescription in the first place. Medical orders are then transferred to the appropriate medical staff or departments, such as pharmacy or laboratory, responsible for fulfilling the order.

Because the CPOE facilitates order completion in an error-reducing manner, allows order entry at either the point of care or off-site, simplifies inventory management, and enables scrupulous error-checking, it was rated the most popular technological tool that hospitals planned to install in 2005 in response to the requirements of California Senate Bill (CSB) 1875. A total of 157 hospitals planned to purchase it, rating it as the technology most efficient and important in reducing and preventing medication-related fatalities.

Nonetheless, the CPOE, despite its many benefits, can introduce new types of errors. In particular, when first implemented it may produce slower order entry than person-to-person communication in emergency situations. There may also be an over-reliance on the technology's error-screening capabilities, which can paradoxically contribute to heightened mortality — as occurred in the Children's Hospital of Pittsburgh's Pediatric ICU following CPOE introduction (Han et al., 2005). Similarly, shortcut or default selections can result in toxic outcomes for obese or elderly patients, while frequent alerts and warnings can interrupt clinical workflow. CPOE requires close supervision to be effective, and users need ongoing training for the system to perform at optimum efficiency.

Electronic Medication Administration Record (eMAR)

Medication administration records are generated whenever a patient receives a medication. They document the specific route, drug, dose, and time that the medication is administered, and also serve to prompt the clinician regarding when to apply the medication and how to schedule the dose. Written MARs can cause minor to major errors due to illegibility of handwriting, incorrect transcription, failure to record a particular medication, or numerous other human errors.

An eMAR can be connected to a pharmacy information system or generated on a stand-alone computer or Web-based platform. Barcode point-of-care systems can also generate eMARs. The eMAR was rated third on hospitals' lists for planned purchase, with 108 hospitals planning to acquire this tool (Spurlock et al., 2003).

A 2009 study published by the Agency for Healthcare Research and Quality also demonstrated that the eMAR can significantly reduce high-risk medication events in nursing homes. More than 300 hours of observed implementation and integration of eMARs across five Midwestern nursing homes — which together housed 3,700 residents — found that the tool significantly improved communication among a variety of users, integrated complex tasks, and generated alerts on medication safety issues (Health Information Technology, 2009). However, staff found it difficult to transition to this new, technologically complex system, and the eMAR tended to highlight deficiencies in the traditional medication process rather than automatically correcting them. Even so, the eMAR brought problems such as omitted medications or late administration into the open and encouraged nurses to address them directly.

Conclusion: Toward an Integrated Medication System

The perfect, most complete, and integrated medical system would require all of these technologies to be connected end-to-end in one seamless process. This would entail CPOE linked to a comprehensive electronic medical record, with nurses administering medications via smart pumps reinforced by bar code point-of-care units that precisely contain all details of each patient's treatment. Spurlock et al. (2003) envision this ideal system as a goal that remains far ahead in the future.

However useful these technologies are — and they certainly are — hospitals and medical institutions can benefit from them only when skilled professionals employ them carefully and consistently. Technology is a powerful tool for reducing medication errors, but its effectiveness ultimately depends on the humans who implement and oversee it.