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Medicines are routinely used to manage patients’ health conditions in the hospital setting. Medication use may range from symptom control to therapeutic interventions.
When done well, use of medicines for patient care in the hospital setting is safe. However, gaps in systems and processes can lead to errors, which may cause harm to patients.
At present, the two important steps of prescribing and documenting the administration of medicines in the inpatient setting at CM Health are paper-based. The paper-based system has many problems, including illegible (handwritten) orders from doctors – some of which may be incomplete – and unfinished records of what medications are administered to patients. In addition, the paper-based process is inefficient. These issues, along with the inability of a paper chart to provide in-time reminders to assist prescribing and administration, may result in medication errors, thereby increasing the risk of harm to patients.
Our baseline data indicates that, on average, there are 7.2 medication errors per admission of a patient; and that potentially one in four admissions will experience a medication error that could result in a moderate to severe adverse event, so that the patient needs additional intervention by healthcare professionals or to spend a longer time in hospital.
International and local studies have shown that using electronic prescribing and administration systems can reduce medication errors and therefore improve patient safety.
This quality improvement initiative aims to reduce medication errors, and the related patient harm, through the use of an electronic prescribing and administration system. MedChart, a trusted and nationally endorsed system, will replace the paper-based system and enable the prescribing and administration process.
MedChart supports doctors, nurses and pharmacists to manage the medication process electronically and also provides system-based smarts, decision aids, alerts, reminders and safety parameters that reduce medication errors and patient harm.
We plan to implement MedChart in all inpatient areas by the end of 2020 and will extend the solution to the outpatient settings in future.
In addition, we aim to increase the efficiency of some of the processes involved in medication management by ensuring interoperability between the different clinical systems. For example, the ability to access a patient’s medication record from anywhere in the hospital or remotely will help clinicians in their decision-making and result in more timely care for patients. Furthermore, linking the prescribing and dispensing systems automates the medicines request process for nurses, freeing up time for them to care for patients. In addition, doctors, nurses and pharmacists no longer have to spend valuable time searching for paper charts.
We have started the implementation of MedChart in our inpatient settings. We have adopted a two-stage (Phase 1 and Phase 2) approach to the implementation of MedChart and are currently progressing Phase 2.
Phase 1 began in April 2018 and was completed October 2018, with MedChart rolled out to 168 inpatient beds across seven of the elderly care and rehabilitation wards.
We used the major learning from our Phase 1 to inform our strategy for the larger roll out in Phase 2. We also completed a robust analysis of the system and its benefits in Phase 1.
MedChart is a significant investment for the DHB, and we wanted to confirm that the safety benefits we anticipated were actually realised in Phase 1.
Following the successful completion of Phase 1, we completed the business case for Phase 2 and as at 30 June 2019 we have implemented MedChart across the Adult Emergency Department and all adult medical wards (approximately 200 beds). Phase 2 will continue to roll out MedChart within the surgical, mental health, women’s health and paediatrics services this year and early next year. The technology will need upgrading as soon as the new version becomes available and this is planned to occur later this year.
We have ensured that the system is robust to ensure security and privacy of information. In addition, we have designed back-up systems and processes to minimise any disruption to care of patients during unplanned outages.
The implementation of MedChart in Phase 1 went well and we used our learning from that phase to develop good support systems for Phase 2. The experience of MedChart for doctors, nurses and pharmacists was largely positive and many reported that MedChart improved patient safety.
We identified that our training and support mechanisms needed to be agile and in real time to fit the needs of a busy hospital setting.
Analysis of our baseline data revealed that medication errors that had the potential to cause harm (adverse drug events) were common occurring in one-in-four patient admissions. We determined that the electronic system could prevent around 68% of those errors. After MedChart was implemented, we looked at the rate of medication errors in a group of patients who had MedChart systems used for their medicines management. We found that these patients had much lower rates of errors and adverse events from medications; confirmed our initial estimates of error reduction. Our rates of error reduction were similar to those seen in an Australian hospital, which also uses MedChart.
We experienced some different challenges during Phase 2 as we rolled out the system to busier acute wards. These challenges were mostly associated with technical issues, and the majority are now resolved. Solutions are being developed for the others. The performance of the MedChart technology has been very good and outage has been rare, providing us with confidence in the system’s resilience.
The implementation of MedChart has improved many areas of medication management and enhanced patient safety. These improvements include:
We also saw some efficiency gains, enabling all clinicians more time to deliver care for patients.
MedChart will continue to be rolled out to the rest of the inpatient units in Phase 2. Furthermore, MedChart enables us to access real-time data on medicines use. We hope to use this data to develop clinical indicators and dashboards, in order to further improve the timely and best use of medicines for patient care in the hospital setting.