Medication Administration, Delivery and Reconciliation Systems

Transcription

1 Medication Administration, Delivery and Reconciliation Systems Foundational Curricula: Cluster 5: EHR Systems Module 9: EHR Modules Medications, Allergies, Clinical Decision Support and Order Entry Unit 1: Medication Administration, Delivery and Reconciliation Systems 27/60 Curriculum Developers: Angelique Blake, Rachelle Blake, Pauliina Hulkkonen, Sonja Huotari, Milla Jauhiainen, Johanna Tolonen, and Alpo Vӓrri 1

2 Unit Objectives Identify technologies related to patient identification within the medicines administration process, including Radio- Frequency Identification (RFID) and bar-coding Describe the basic mechanisms of electronic prescribing (eprescribe), electronic medication administration, barcoding and RFID, and medication reconciliation Describe how electronic systems can support the medication supply, delivery and administration processes in hospitals and other clinical settings Examine how technology affects the medication prescribing, delivery and administration process Define the health IT/eHealth principles of electronic prescriptions and bar-code administration 2

3 Patient Identification Patient identification involves making sure the person who is receiving health care is formally recognized and differentiated from others The matching of a patient to an intended treatment is an activity that is performed routinely in all care settings. Risks to patient safety occur when there is a mismatch between a given patient and components of his or her care, whether these components are related to diagnosis, therapy or support The primary importance of patient identification is for the safety of the patient, but is also for the benefit of healthcare providers, insurance companies and government entities, and continuity of care 3

4 Patient Identification (cont d) Patient identification is made simpler with electronic devices such as bar codes, EHRs, and other system supports The most common treatment error associated with misidentification is that of a patient receiving a medication intended for another patient. However, this is only one of many potential errors that can be caused by misidentification, including: incompatible blood transfusion reactions incorrect diagnostic tests being given being unaware of medication or food allergies failure to treat a serious illness or disease medical treatment for erroneous diagnostic lab results procedures being performed on the wrong site or wrong patient 4

5 Mechanisms Used in Identification Systems There are several types of mechanisms used in identification systems. Some of these identification systems are used to identify patients, while the same or other systems can also be used to identify products, such as computer devices, medical supplies or equipment, other hospital inventory, or medications Commonly used healthcare identification systems include: barcode scanning systems radio frequency identification systems biometric systems 5

6 Barcode Scanning Systems A barcode is an optical, machinereadable, representation of data; the output usually describes something about the object that carries the barcode A barcode reader (or barcode scanner) is an electronic device that can read and print out barcodes to a computer. The scanner consists of a light source, a lens and a light sensor translating optical impulses into electrical ones Unlike the RFID, which we will explain later, the barcode needs a visual connection between the code and the scanner 6

7 Barcode Scanning Systems (cont d) Barcodes can be linear (one-dimensional, 1D) or matrix (two-dimensional, 2D) (with pixels rather than lines) Types of linear barcodes include: basic alphanumeric code, used for supplies and equipment one-track pharmacode, used for medications two-track pharmacode, used for medications International Society of Blood Transfusion (ISBT) code 128 Types of matrix barcodes include: Aztec code, named after the resemblance of the central finder pattern to an Aztec pyramid, is used in medication administration QR code (Quick Response code), popular for mobile tagging applications, is used in marketing Data matrix code, which encodes text or raw data in a pattern of black and white square modules, is used by the pharmaceutical industry for unit dose and product marking (product labeling) one-track pharmacode Aztec code alphanumeric ISBT code 128 QR code two-track pharmacode Data matrix code 7

8 Barcode Scanning Systems (cont d) Barcodes are frequently used in patient identification, medication identification, blood transfusions, and the medication administration process Barcodes can be read with optical scanners, smart phones and other devices With a linear barcode, this is done by reading the varying widths and spacing of parallel lines on a medicine container or patient wrist band With a matrix barcode, which is used for encoding a large amount of data characters, often necessary for very small containers, this is done by reading the pixels or matrixed components of the barcode 8

9 Barcodes used in Healthcare Barcodes are used in: Hospital wristbands For patient identification, electronic health record integration Medication identification and management Labeling of medications, containers and dispensing devices Labeling of unit dosing Specimen collection and blood infusion Easier and safer method for labeling samples Supplies and medical equipment Surgical instruments and medical device sterilization Barcodes are less expensive than RFID Ideal for stationary humans and moving objects, e.g. blood sample collection and analysis 9

10 Radio-Frequency Identification (RFID) Radio-Frequency Identification (RFID) is a method that uses electromagnetic fields and radio frequencies to identify, track and scan nearby tags specified for this purpose Passive tags collect energy from nearby RFID reader s radio waves Active tags have their own local power source, thus they can be read from further distance than passive tags RFID does not require straight visibility between reader and the device thus the tags (and readers) can be hidden inside devices or clothing (or skin, which, for example, is used to identify pets) 10

11 Radio-Frequency Identification Uses in Healthcare Some organizations utilize RFID integrated into identification cards or bracelets to identify patients RFID is more commonly used to identify equipment, devices and other valuable articles used in the healthcare setting RFID tags can store information regarding the patient information or conditions, such as whether the patient has been in contact with infectious diseases This can aid in achieving infection control and other processes 11

12 Radio-Frequency Identification Uses in Healthcare (Cont d) RFID tags are also used in hospital equipment and medication RFID tags are located in radiation protection vests to locate them faster during an inspection RFID tags can be used to keep track of supplies New orders are placed only when the information systems report the supply is running out RFID can also be used to reduce supply overstock RFID 12

13 Biometric Systems Biometrics refers to metrics related to human characteristics. Biometrics can be grouped into physiological and behavioral characteristics Physiological characteristics include attributes of a person s body and its parts. Behavioral characteristics are related to the pattern of a person s behavior Biometrics authentication is used in ehealth as a form of patient identification, system user identification, and device or electronic record access control Biometric identifiers are the distinctive, measurable characteristics used to label and describe individuals. Common biometric identifiers used in ehealth include: fingerprint face recognition DNA palm print hand geometry iris recognition retina recognition signature voice recognition 13

14 Biometric System Modes There are two basic modes of any biometric system: verification and identification In verification (or authentication) mode, the system performs a one-to-one comparison of a captured biometric identifier with a specific template stored in a biometric database. This is done to verify the individual is the person they claim to be Three steps are involved in verification: generating reference models for all users, and storing them in the model database matching the samples with reference models to generate the genuine and impostor scores and calculate the threshold performing testing against the stored template; secondary identifiers such as a smart card, username or ID number may also be used for comparison 14

15 Biometric System Modes (cont d) In identification mode, system performs a one-tomany comparison against a biometric database in an attempt to establish the identity of an unknown individual The system will succeed in identifying the individual if the comparison of the biometric sample to a template in the database falls within a previously set threshold Identification mode can be used for two types of recognition: Positive recognition, where the user does not have to provide any information about the template to be used Negative recognition, where the system establishes that the person is who he or she (implicitly or explicitly) denies being Negative recognition can only be achieved through biometrics, since other methods of personal recognition such as passwords, PINs or keys are ineffective 15

16 BCM, RFID, Biometrics and Medication Administration The medication preparation, dispensing and administration process can be enhanced with RFID, barcode scanning, and biometrics Single and multiple dose medications can be prepared or packaged with RFID and barcodes. This is frequently used for IV preparations, unit dose medications, chemotherapeutic drugs, and other pharmaceuticals Medication dispensing devices such as Pyxis machines can also utilize biometrics for user access, such as for nurses and nursing assistants Inpatient and outpatient prescription drugs can be tracked and traced with barcodes via charge capture 16

17 Electronic Prescribing (e-prescribing) Electronic prescriptions (eprescribing, or erx) is the computer-based electronic generation, transmission and filling of a medical prescriptions eprescribing replaces paper and faxed prescriptions once electronic health records have been implemented eprescribing allows a medical provider (physician, pharmacist, nurse practitioner, or physician assistant) to electronically transmit a new prescription or renewal authorization to an outpatient, community or mail-order pharmacy eprescriptions contain the same information as would be placed in paper prescriptions, except electronically. They are transmitted from the doctor to the pharmacy system faster than the patient could transport the paper prescription Patient identification processes for picking up the medications may vary by location, and may be a combination of some form of self-identification, such as passport, driver s license, two-factor identification, or other ID depending on the country policy 17

18 Benefits of e-prescriptions eprescribing enables providers to send error-free, accurate, and understandable prescriptions electronically from their offices or clinics directly to the pharmacy The process can reduce many of the risks associated with traditional prescription writing, including: Avoiding the need to interpret a provider s handwriting and instructions Reducing prescribing and dispensing errors Decreasing the work needed to create and fill a prescription Speeding the receipt of prescribed drugs to patients Preventing adverse drug interactions and reactions Providing more availability to substitute less expensive drug alternatives by checking the formulary of the insurance provider in the doctor's office Improving medication compliance (having the patient take the prescribed medications on time) by reducing lost and unfilled prescriptions and minimizing patient costs Reducing the incidence of drug diversion (drug abuse) by alerting providers and pharmacists of counterfeit prescriptions or duplicative prescriptions for controlled substances 18

19 Electronic Medication Administration Record (emar) The electronic medication administration record (emar) is the electronic report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional The MAR is used in hospitals worldwide, and is replaced by the emar in hospitals that have electronic health records 19

20 emar Content The actual emar content varies from hospital to hospital and country to country. However the record typically contains this format: Administrative/Demographics Patient Name (often Surname, First name, Middle Initial) and other identifying data Date of Birth / Age Treating team details Allergies Other, variables: weight, special diet, oxygen therapy, application time of topical local anaesthetics, e.g., Eutectic Mixture of Local Anesthetics (EMLA) 20

21 emar Content (Cont d) Prescription/Medication Details Drug name Medication type / classification Dosage strength Route Frequency Medication indication / Diagnosis Tracking capabilities Prescribing provider details The emar relays drug dosage data to the pharmacy, which is then connected to hospital nursing stations 21

22 Benefits of the emar Benefits of the emar include: The provider is able to order, re-order, refill and add medications directly in the emar. In addition, an emar: Improves quality of care and safety Requires less manual data-entry Eliminates the need for paper orders and prescriptions in the hospital Provides drug interaction and allergy flags and alerts Provides audit tracking tools and enhanced security with user authentication Reduces or eliminates physician and pharmacy error rates Documents the patient s real-time medication history and refill history Provides access to all historical administration information on demand Promotes real time information exchange among users Increases efficiency by processing medication orders in real time Enhances the integrity of the EHR Helps organizations on their journey to a paperless system 22

23 The Five Rights of Medication Administration The EMAR can help the bedside nurse ensure the five rights of medication administration are met: 1. Right patient 2. Right drug 3. Right dosage 4. Right route 5. Right time 10 cc 23

24 The Five Rights of Medication Administration (Cont d) Procedures for ensuring each of the Five Rights must take into account human factor and systems design issues (such as workload, ambient distractions, poor lighting, problems with wristbands, ineffective double check protocols, etc.) that can threaten or undermine even the most conscientious efforts to comply with the Five Rights In the end, the Five Rights remain an important goal for safe medication practice, but one that may give the illusion of safety if not supported by strong policies and procedures, a system organized around modern principles of patient safety, and a robust safety culture 24

25 Medication Reconciliation Medication reconciliation is the process of comparing a patient's medication orders to all of the medications that the patient has been taking It includes reconciling medications across all encounters of care, including acute care episodes (hospital admissions), outpatient care, and other care episodes There are three steps to medication reconciliation: 1. Verify by collecting the list of medications, vitamins, nutritional supplements, over-thecounter drugs, and vaccines 2. Clarify that the medications and dosages are appropriate 3. Reconcile and document any changes 25

26 Medication Reconciliation (cont d) Medication reconciliation involves: creating the most accurate list possible of all medications a patient is taking comparing the list against the most recent medication list, pharmacy records, or physician s orders ensuring all ongoing outpatient medications are known on admission to a hospital or emergency room ensuring all discharge medications are communicated to the patient s primary care provider Some transition points that require special attention include: Admission to a hospital Transfer from the emergency department to other care areas Transfer from the intensive care unit to the nursing ward Discharge from the hospital to home, aged care home or another care facility 26

27 Contents of Medication Reconciliation A medication reconciliation list should include: All information from any emar Outpatient medications: Name of the drug Dosage Frequency Route A comprehensive list of medications should include all prescription medications, herbals, vitamins, nutritional supplements, over-the-counter drugs, vaccines, diagnostic and contrast agents, radioactive medications, parenteral nutrition, blood derivatives, and intravenous solutions (hereafter referred to collectively as medications) Over-the-counter drugs and dietary supplements are not currently considered by many clinicians to be medications, and thus are often not included in the medication record. However, as interactions can occur between prescribed medication, over-the-counter medications, or dietary supplements, all medications and supplements should be part of a patient s medication history and included in the reconciliation process 27

28 Benefits of Medication Reconciliation More than 40 percent of medication errors are believed to result from inadequate reconciliation in handoffs during admission, transfer, and discharge of patients Of these errors, about 20 percent are believed to result in harm to the patient Many of these errors could be averted if medication reconciliation processes were in place Medication reconciliation can reduce or prevent: errors of omission duplication of medications incorrect doses or timing adverse drug-drug or drug-disease interactions Medication reconciliation provides the ability to import and export medication lists from and into EHR/EMRs 28

29 EHR Support of Care Processes in Clinical Settings In this unit we have identified several technologies for patient identification and other healthcare processes that are aided with identification systems, such as prescribing and medication administration Patient, device and product identification technologies have many benefits in healthcare. They help provide: Quality of care improvements Verification and validation of patients and users Accuracy of information, with no interpretation or transcribing needed Safety and security, with reduction of errors Enhanced integrity of electronic information Electronic processes are faster and more efficient than paper and manual processes Universality, interoperability and standardization of information 29

30 Unit Review Checklist Identified technologies related to patient identification within the medicines administration process, including Radio-Frequency Identification (RFID) and bar-coding (SB02) Described the basic mechanisms of electronic prescribing (e-prescribe), electronic medication administration, barcoding and RFID, and medication reconciliation (MB04) Described how electronic systems can support the medication supply, delivery and administration processes in hospitals and other clinical settings (MB02) Examined how technology affects the medication prescribing, delivery and administration process (MB03) Defined the health IT/eHealth principles of electronic prescriptions and bar-code administration (ML02) This work is produced by the EU*US ehealth Work Project. This project has received funding from the European Union s Horizon 2020 research and innovation programme under Grant Agreement No

31 Unit Review Exercise/Activity Select the correct barcode on the right with the following questions: 1. What type of barcode would typically be used with blood to be transfused? 2. What type of barcode would likely be used for hospital marketing purposes? 3. Which two linear barcodes might be used for medication labeling? 4. Which two matrix barcodes might be used with medication administration? one-track pharmacode Aztec code alphanumeric ISBT code 128 two-track pharmacode Data matrix code QR code 31

32 Unit Exam (cont d) 3. Which of the following statements is true about barcodes? a. A linear barcode is one-dimensional and made of lines b. A matrix barcode is one-dimensional and made of pixels c. An Aztec barcode is an example of a linear barcode d. A two-track pharmacode is made of pixels 4. Which of the following processes does not require straight visibility between reader and the device? a. barcode reading b. biometric identification c. RFID reading d. one-track pharmacode reading 32

33 Unit Exam (cont d) 5. emar stands for a. Effective Medical Administration Rules b. Electrical Maintenance in Acute care Rooms c. Electronic Medication Administration Record d. Electronic Medication Automation Record 6. Medication reconciliation means a. Listing all medications, vaccines, vitamins and other drugs that the patient from encounter to encounter b. Listing the prescription refill history of the patient c. Creating a list of drugs that the patient is allergic to d. Calculating the optimal dosage of a drug for maximal effect and minimal adverse effects 33

34 Unit Exam (cont d) 7. The five rights for medication administration include all of the following, except: a. right patient b. right dosage c. right route d. right side 8. Which of the following is not a step involved in biometric verification? a. generating reference models for all users b. matching the samples with reference models c. performing testing against the stored template d. negative recognition 34