New pharmacy IT, keep in mind priorities and environmental issues

Smart installation can save time, prevent mistakes

Hospital pharmacy directors should expect some continued work and complications even after they've successfully installed new technology to assist with improving medication safety.

"People want this magical answer, and there isn't one," says Leslie Mackowiak, MS, RPh, director of clinical applications at Vanderbilt University Medical Center in Nashville, TN.

"They need to be thoughtful when they put it together because it's a very tightly coupled system," Mackowiak says. "If they start with barcode medication administration, they'll need to make adjustments later when they install a computerized physician order entry (CPOE) system."

The same consideration and adjustments need to be made when the reverse order is followed.

Paper processes require continual adjustments that are made manually by pharmacists, nurses, and physicians. With electronic systems, these adjustments have to be anticipated or identified and made in a systematic way, Mackowiak notes.

"Your system has to understand all of the business rules that probably are not written down," she explains. "We don't think about the decisions we make because this is a natural part of what pharmacists do, but now we have to explicitly address these in a computer system."

Mackowiak offers these suggestions on how to ensure new technology will continue to work efficiently, safely, and successfully:

1. Analyze data to ensure the technology is working properly.

After new technology is installed, an information technology expert and/or a pharmacy director need to analyze data to make certain everything is working as intended.

For example, if the hospital has installed barcode technology, then the analysis should look at the medications being scanned, scan rates, and scan times, and how well this is working, Mackowiak says.

If there appears to be a problem with barcodes on a particular medication, then this should be investigated further and corrected.

The goal is to analyze data for the purpose of improving the process, perhaps through system improvements or by providing nurses or other staff with more education on prescribing and administering medication, Mackowiak says.

"In a manual system, pharmacy might know what's happening with system problems, but now you have electronic data, and you need the skills necessary to report the data and then interpret it," she adds.

2. Determine reasons for data mistakes.

Sometimes when pharmacy leaders review data from new technology they'll find problems, such as medications not being given as required or incomplete documentation.

Nurses are required to give reasons for not administering medications as ordered, but their explanations might raise more questions than answers.

"Their answers might not make sense," Mackowiak says.

"Some nurses may interpret the words differently than they were intended," she adds. "So you might not be able to use the data in the first pass, and you'll have to clean up the misinterpretation."

For instance, Mackowiak learned that the reasons listed for not administering a drug did not adequately fit the situations. The problem was the list of possible reasons was too long, and some nurses would just select an answer at the top of the list.

"We weren't sure we had good data about why nurses had not given medications," she says. "Is it a process issue, an over-prescribing issue, or did a lot of patients and families refuse the drug?"

It became necessary to sacrifice some detail in documentation for the sake of greater accuracy.

"Some nurses wanted to be very precise in their answers, but we had to say, 'No,' because the other nurses would give us the wrong answers because the list was too long," she explains.

The electronic documentation seemed like an easy solution, but actual practice showed it to be amazingly complex, Mackowiak adds.

"So we asked a committee to decide how we could better describe and define the reasons on the list and what we should do to get clearer data," she says.

They decided to shorten the answer list and improve education on why it was important to document these explanations.

3. Systematically check for mistakes.

"If we have a CPOE system, and we have prescribing errors, what does that mean?" Mackowiak says. "How do we resolve that to improve decision support?"

Even with a technological solution, patients can be put on the wrong drugs or wrong dosages.

"We did an audit of all prescribing errors at another institution and saw that the majority of prescribing errors were problems of patients not being given the right initial dosages of drugs, so we looked at how we could improve that," Mackowiak says.

That problem was the lack of flow between the home med list and the inpatient list, so the solution was to improve the view of home list when physicians are admitting patients.

"You have to go back and forth between these systems to double-check and make sure you've thought through your problem all the way," she suggests. "You can't make a change at one end without thinking it through and testing it."

4. Test, retest, and test again new technology and systems.

System mistakes resulting in wrong medication dosages can happen many years after new technology is installed, according to Mackowiak who has seen this situation arise.

"It was three years later that we created this error," she says. "That's why you need constant vigilance when you make any change in a system."

Pharmacy directors should not rest, thinking the work is done once the new technology is installed and pilot-tested. Instead they need to keep testing and checking for problems and workflow issues.

One way to make these double-checks systematic is to create testing documentation for changes. Each time a change is introduced, the decision tree will instruct pharmacy staff on what to do next and what questions to ask.

Also, staff training is another way to keep staff vigilant in looking for problems.

"The more training you have and the more experience you have, the better you understand the system and will know where in the information technology system you could catch mistakes," Mackowiak says.