Beside Medication Verification Reduces Errors

Time Frame: Began October 2004, completed September, 2008.

Description: The purpose of this project, which was funded by a grant from AHRQ, was to reduce medical errors and adverse events at the Southwestern Vermont Medical Center (SVMC) through several information technology innovations including the expansion of electronic health records (EHRs) at the hospital, the introduction of EHR practice management software to the community, the introduction of bedside medication verification and electronic medication administration records (eMARs), the use of recorded nurse-to-nurse shift reports, the implementation of computerized physician order entry (CPOE), and the implementation of Midas+ clinical decision support (CDS) software.

In addition, SVMC undertook a major initiative to improve organizational culture around patient safety. Leadership made a conscious effort to shift organizational culture from one that discouraged disclosure and blamed individuals for medical errors to one that promotes disclosure, seeks out root causes, and implements systemic improvements in clinical practice to improve patient safety.

The original scope of this project was to implement EHR technologies throughout SVHC’s several organizations and in privately-owned medical practices in the community. During the first year of implementation, however, it became clear that the job of moving forward with EHR was a much larger and more complex task than had been originally anticipated. Therefore, the scope of the project was tightened, focusing year two only on the introduction of EHRs and related technologies at the hospital. By year four, some issues with the implementation of EHRs in area private practices had been resolved, and again began to move forward, while implementation of EHRs at the hospital continued. For six months prior to the implementation of eMARs, during the five month implementation window, and for five months after full implementation, the head of Pharmacy examined all the medication-related events submitted through SVMC’s internal reporting system (based on self-report), and identified actual errors in transcription, administration, and near misses for the four types of medication errors (ordering, transcription, dispensing, and administration).

Project Goals: The specific aims for this project included the following:

• Assess the development of a “culture of safety” through educational programs, administrative efforts, and the implementation of health information technology. (Achieved)
• Develop a new protocol for nursing shift reports and assess its impact on completeness of reporting; implement voice recording technology to supplement the report and assess its effects. (Achieved)
• Implement bedside medication verification and electronic medication administration records and assess their value in reducing errors. (Achieved)

Project Results: Our research goal was to understand if the implementation of bedside medication verification and the use of an electronic medication administration record (eMAR) would decrease certain types of medication errors. Error reduction has been a hallmark of the patient safety effort at SVMC, so the introduction of this technology was seen as a critical component. Through this study we examined two types of medication errors: a) transcription errors and b) administration errors as we felt that bar coding and eMAR technology had the greatest potential to reduce the error rate.

Transcription errors: As long as there is human interface between the physician’s written order and the medication administration record, there is the potential for transcription errors. While the implementation of eMAR did not eliminate the process of transcribing a handwritten physician order onto the MAR, our project does show a reduction in the reports of those types of errors. When we compared rates of transcription errors before, during and after the implementation of eMAR, we found that as we anticipated, the number of reported transcription errors decreased significantly.The difference between the mean transcription errors in the pre E-mar (paper) period (1.22 per 10,000 doses) and the period after implementation was complete (0.50 per 10,000 doses) is significant at the p = .01 level.

Administration errors: Administration errors are those that happen during the process of giving the medication to the patient. Assuming the nurse even knows that s/he gave the wrong medication, these types of errors tend to be reported more often than transcription. A major goal of the eMAR system was to intercept potential administration errors before they occurred, but alerting the nurse that there was some mismatch between the patient, the medication, and the MAR.

Perhaps because of the eMAR warning system, administration errors also decreased over the study period, with means of 2.63 per 10,000 doses prior to e-MAR, 2.41 per 10,000 doses during implementation, and 1.77 per 10,000 doses after implementation was complete. This difference between the pre and post-implementation periods, however, did not reach robust statistical significant (p = .20).