closed loop medication process in a teaching hospital in 9 … · closed loop medication process in...
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Closed loop medication process in a teaching hospital in 9 months
LUIS MARTINEZ ESCOTET, MD
e-huca+ project manager
Hospital Universitario Central de Asturias
Where are we located?
We are at the North of SpainOviedo is Principality of Asturias capital city
HEALTHCARE GEOGRAPHIC DISTRIBUTION
1,075,948 citizens
HEALTHCARE GEOGRAPHIC DISTRIBUTION
HEALTHCARE GEOGRAPHIC DISTRIBUTION
989
2,700 beds
HEALTHCARE GEOGRAPHIC DISTRIBUTION
Hospital Universitario Central de Asturias
(HUCA).
Oviedo, Spain
Tertiary care teaching hospital. 989 beds
7 adult intensive care units (ICU), 1
neonatal ICU, 1 pediatric ICU
GESTION DEL CAMBIO WWW: ayuda de los sistemas de información
WEB 1.0
Data recorder
Not interface
WEB 2.0
P2P
Virtual communities
Information share
WEB 3.0
semantic web
Using metadata and tags
Natural Language
SNOMED y Semantic Search
TIC’S EVOLUTION
• Paper medical records
• Handwritten medication orders
JUNE 2014: hospital move and model change
• Electronic medical records
(EMR)
• Computerized prescriber order
entry (CPOE)
• Clinical decision support
systems (CDSS)
From To
• Illegible handwriting
• Transcription errors
• Lack of traceability
• No access to the full medical history
Advantages & disadvantages
• Real-time access to patient records
• Avoid transcription errors and illegible
issues
• Improve workflow efficiency
• Help prescribers with decision
support systems
• New type of medication errors
11 / XX
GESTION DEL CAMBIO: AJUSTE DE PROCESOS
Adverse events, which represent
between 3% and 5% of all hospital
admissions in the UK, costing the
NHS around 500 million GBP
Hospital errors leading to
preventable adverse events,
typically occur in:
34%4%56%
The cost of care based on memory
Medication management during the
entire cycle
CVLab
Rad
•Computerized
prescriber order
entry (CPOE)
Indications
managemet
Pharmacy
Management
Electronic
medication
administration
In Spain, adverse events accounted for 3.47% of
admissions in large hospitals (ENEA). According to
AHQR (Agency for Healthcare Research and
Quality's) each adverse event linked to medication
costs about € 3,200.
In UE, make a mistake until 60 million in non-electronic
prescriptions per year, (3% of all prescriptions issued)
With a 40% adoption of electronic prescribing, 40% of the errors
could be avoided
British Journal of General Practice.
CPOE+CDSS reduce prescribing errors. However, they have no
effect on medication administration errors. ‘Closed loop’
medication management systems, which combine CPOE+CDSS
with other proven technologies to prevent errors at each step
of the medication pathway, show great promise for preventing
clinical adverse events.
Ranji SR, Rennke S, Wachter RM. Computerised provider order entry combined with clinical
decision support systems to improve medication safety: a narrative review. BMJ Qual Saf
2014;23:773–780.
Closed loop medication process
Pharmacy Inpatient Formulary: 2,070 products
CPOE
2,254 Inpatient Medication Orders (Indications)
CPOE
4,765 Inpatient Medication Order Sentences
CPOE
Search options:
• Drug name
• Brand name
CPOE
Using Tall Man Letters for look-alike drug names to reduce confusion
between similar drug names (following ISMP recommendation)
CPOE
IV Sets: 1,015- Continuous infusion: 752- Intermittent infusion: 263
CPOE
IV sets
• Standardization in critical drugs (amiodarone, dobutamine,…).
• Standardization in IV sets preparation (instructions for nurses).
• Use of low-volume fluids to reduce the % of positive fluid balances.
• Avoid compatibility problems.
CPOE
Medication containing PowerPlans: 362
CPOE
A. Drug powerplans
CPOE
B. Clinical situations powerplans
CPOE
Intravenous fluid therapy powerplans: 27
CPOE
ICU PowerPlans: 77
CPOE
NICU PowerPlans: 69
CPOE
PICU PowerPlans: 29
CPOE
Emergency PowerPlans: 27
CPOE
Anesthesia PowerPlans: 15
CPOE
Cardiology PowerPlans: 23
CPOE
Intoxication management PowerPlans: 13
CPOE & CDSS
Intoxication management PowerPlans
CPOE & CDSS
Therapeutic Interchange Program PowerPlans: 135
Therapeutic alternative for 223 drugs
CPOE & CDSS
Therapeutic Interchange Program PowerPlans
CPOE & CDSS
PowerPlans signed in a week
0
18
35
53
70
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dic
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CL
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AC
V
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.
CPOE & CDSS
Indications included in PowerPlans signed in a week
0
250
500
750
1000
Méd
ico
ACL
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
CPOE & CDSS
Flowsheets and quick indications
CPOE & CDSS
Flowsheets and quick indicationsCPOE & CDSS
Drug alerts: Interactions
CPOE & CDSS
Drug alerts: Therapeutic Duplications
CPOE & CDSS
Drug alerts: Allergies
CPOE & CDSS
Drug alerts
Fatigue
To avoid alert fatigue:
• Inactivation of non clinically significant drug-drug interactions.
• Daily review of alerts to eliminate non significant ones.
Autovalidation increase
CPOE & CDSS
Other alerts: Dose Range Checking
CPOE & CDSS
Other alerts: using Rules
Intravenous to oral therapy conversion
CPOE & CDSS
Other alerts: using Rules
Intravenous to oral therapy conversion
CPOE & CDSS
Pharmacist Interventions: clinical interventions
CPOE & CDSS
Pharmacist Interventions: reporting Adverse Drug Reactions
CPOE & CDSS
Pharmacist Interventions: compassionate-use
CPOE & CDSS
• Implemented in May 2015
• Developed and used in hematology: conditioning regimens and
GVHD prophylaxis.
• Will be used for Ambulatory Treatment Center indication and
administration: not only chemotherapy.
• Need of onco-hematology treatments standardization.
Oncology CPOE
Oncology CPOE
Oncology CPOE
Oncology CPOE
CERNER integrations at Pharmacy Department
Indication Pharmacist Validation
Dispensing
Inventory management
Safe drug administration: BCMA
Bar-code medication administration
(BCMA)
• Implemented in Child and Adolescent Inpatient
Psychiatric Unit.
• All medications dispensed from Pharmacy
Department with bar-code identification.
• Nurses trained in bar-coding.
• Reduces administration errors.
Safe drug administration: BCMA
HiMSS Analytics Stage 6 - April 2015
Outpatient Pharmacy - Retail
Pharmacy Outpatient Formulary: 432 products
432 Outpatient Medication Prescriptions
Outpatient Pharmacy - Retail
464 Outpatient Medication Prescriptions Sentences
Outpatient Pharmacy - Retail
• Implemented in July 2014.
• 5,000 patients per year (HIV, HCV, HBV, Multiple Esclerosis, Cancer patients).
• Retail integrated with a robotic dispensing system.
Outpatient Pharmacy - Retail
✓ Smart infusion pumps
• Infusion pumps with software that can alert users
to potential errors.
• Library of drugs that provides medication dosing
guidelines, by establishing concentrations, dose
limits, and clinical advisories.
• Indications ready to use the new pumps.
✓ PowerChart Oncology integration with LUG technology
• Drug preparation work sheets on screens
inside biosafety cabinets.
• Voice commands.
• Bar-code technology.
• Computer-assisted gravimetric production
control.
✓ Implement BCMA in the rest of units.
✓ Specific order sentences for weight and age ranges.
✓ Increase dose range checking alerts: new drugs.
✓ Include new alerts, new rules: e.g. antibiotic treatment
duration.
✓ Develop Discern Analytics 2 reports to link indications with
clinical parameters: e.g. erythropoietin and hemoglobin levels.
Conclusions
1. Closed loop medication process improve
patient safety reducing medication errors.
2. Development of the tools we have will lead
our institution to increase patient safety
and reach a high-quality care.
68Thank you for your attention