Introduction of EPMA in paediatric practice in UK:

Transcription

1 Introduction of EPMA in paediatric practice in UK: REALISING THE CLINICAL BENEFITS AND ENGAGING CLINICAL STAFF Stephen Marks Consultant Paediatric Nephrologist and EPMA lead Great Ormond Street Hospital for Children and UCL Institute of Child Health, London, UK. Electronic Prescribing in Hospitals, 22 January 2013

2 Electronic prescribing and medicine administration (EPMA) Over 5% of hospital admissions result in an adverse event resulting from the use of medicines Vincent et al (2001) BMJ, Bates et al (1995) JAMA GOSH audit showed missing data in 34-53% Rx incomplete recording of allergies, weights, consultant Why change to EPMA? EP used in PCT s and adult secondary care CLINICAL RISK MANAGEMENT OPERATIONAL EFFICIENCY ELECTRONIC PATIENT RECORD

3 Children are not small adults

4 Paediatric medication errors 0.15% % of all paediatric admissions Ross et al (2000), Wilson et al (1998) 5.7% % of all prescriptions Kaushal et al (2001), Marino et al (2000) Fontan et al (2003), Kozer et al (2002) 4.5% % of all administrations Nixon et al (1996), Schneider et al (1998)

5 How serious is prescribing? 0.4% of Rx contain errors with 1% fatal and 12% life-threatening 42% fatal / life-threatening / serious were preventable 28% of all adverse events were preventable Main contributory factors of adverse events prescribing errors 62% administration errors 34% dispensing errors 4% Bates et al (1995) JAMA, Leaser et al (1990/1999) JAMA

6 Managing clinical risk Introduction of electronic prescribing and associated on-line decision support can reduce serious adverse drug events by 55% From 10.7 to 4.86 per 1000 patient days Bates et al (1988) JAMA

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11 Aims Primary aim was to introduce first EPMA system adapted for paediatric inpatient and outpatient use in the UK in order to reduce the incidence and severity of medication errors Secondary aims were to improve adherence to protocols and local formulary to provide MDT members with real time patient medication profiles to allow immediate electronic transmission of medicine requests to the Pharmacy Department to facilitate clinical audit

12 Methods Our Trust s project board and project team selected a company committed to working with us to develop EPMA system (proven in adult setting) to provide functionality required for EPMA in paediatric practice EPMA system introduced in Nephro-Urology in view of diversity and complexities of patients

13 How does EP reduce clinical risk? Unambiguous Rx & administration records

14 How does EP reduce clinical risk? Decision support allergy checking drug interaction alerts therapeutic duplication alerts formulary, protocols, (pathways,) etc. maximum and minimum dose checking route, dose and frequency defaulting

15 How does EP reduce clinical risk? Audit Integration with Pharmacy stock control / ordering work-load prioritisation / progress checking financial information

16 Results The system ensures that key demographic and clinical data are recorded before prescribing need weight, height and allergies or update before Rx 100% completeness, availability and legibility of both patient demographic and medicine data reduction in time spent looking for the drug chart streamlining of the Rx renewal process from pharmacy

17 Pilot data Improvements in prescribing compliance with Trust Policy for writing prescriptions from 37% to 96% 46% -> 93% improvement in accuracy of transcription from inpatient to discharge Rx compliance with Trust policy on recording administration from 65% to 100% date and time stamps with named prescriber

18 Peripheral hardware

19 Electronic prescribing at GOSH Facility requirements ward upgrades computer upgrades Training requirements doctors nurses pharmacists prescribers including supplementary and independent

20 Cultural issues doctors nurses pharmacy staff medical records etc. Issues at GOSH Hardware & infrastructure Software Training Clinical governance validation, security, resilience Finance

21 EP benefits Reduction in number of drug errors allergies / interactions / duplications eliminate transcribing errors Reduction in time wastage streamline prescription renewal process pharmacy prioritisation eliminate the drug chart search

22 EPMA has already proved robust and dependable we are continuing to study its effectiveness in improving the safety and efficiency of prescribing Conclusions MDT embraced this project with enthusiasm and found it to be very helpful in Rx and administering medicines within a HDU paediatric environment

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24 Christine Booth Senior Pharmacist - EPMA

25 NPSA - Safety in Doses: key actions to improve medication safety Minimise dosing errors Ensure medicines are not omitted Ensure correct medicines are given to the correct patient Document patients medicine allergy status Safety in Doses:Medication Safety Incidents in the NHS. The Fourth report from the Patient Safety Observatory. NPSA 2007

26 ep Benefits - medication safety Reduction of drug errors Up-to-date weight mandatory for prescribing Warnings drug allergies, interactions, therapeutic/exact duplicates Calculate dose function TTA/transcription errors eliminated Administrations have to be reconciled Scanning wristbands/intelligent storage Entry of allergy status mandatory

27 ep Benefits - Research at GOSH Pre-eP (n=1574) Renal outpatients clinic ep significantly reduced errors Complete prescriptions Illegibility eliminated Post-eP (n=648) Prescribing errors 77.4% 4.8% Essential info missing 73.3% 1.4% Illegible 12.3% n/a Error-free patient visits 21% 90% Jani YH et al. Electronic prescribing reduced prescribing errors in a pediatric renal outpatient clinic. J Peds: 152(2): Feb 2008

28 ep Benefits - Research at GOSH Inpatient, discharge & outpatient prescriptions Dosing errors Before ep 2.2% (88 of 3939 items prescribed) After ep 1.2% (57 of 4784 items prescribed) 1% absolute reduction (p<0.001chi squared test 95% CI 1.6% to 0.5%) Decrease in severity ratings of dosing errors Jani YH. Electronic Prescribing in Children (EPIC): an evaluation of implementation at a children s hospital. PhD Thesis, SOP, Univ of London, Sept 2008 (ISBN ) Jani YH et al. Paediatric dosing errors before and after electronic prescribing. Qual Saf Health Care :

29 Medication errors in Paediatrics Study carried out in 2004/5 (Ghaleb et al) Paediatric non-ep IP wards of 5 London hospitals ~3,000 prescriptions 13% prescribing errors ~1,550 administrations 19% error rate Ghaleb MA et al: The Incidence and nature of prescribing and medication administration errors in paediatric inpatients. Arch Dis Child 2010:95:

30 Breakdown of EP Incident Reports received (426) Oct 2005-Dec % 1% 27% 40% Pres Admin ICT Not EP Misc 28%

31 0.25 Number of prescribing incidents reported/100 items prescribed (3,517items) 2006 (29,185 items) 2007 (48,641 items) 2008 (74,116 items) 2009 (125,884 items) 2010 ( items) 2011 ( items)

32 0.25 Number of administration incidents reported/100 items prescribed (3,517items) 2006 (29,185 items) 2007 (48,641 items) 2008 (74,116 items) 2009 (125,884 items) 2010 ( items) 2011 ( items)

33 COMMUNICATION DRUG DUPLICATED DRUG NOT DISCONTINUED/SUSPENDED DRUG NOT PRESCRIBED PROCESS - EP/PAPER PROCESS - WT/ALLERGY ENTRY STAT DOSES SYSTEM TIME TAKEN TRANSCRIPTION ERROR UNFAMILIAR/UNABLE/UNWILLING TO PRESCRIBE WRONG DOSE WRONG DRUG WRONG FREQUENCY WRONG PATIENT WRONG START DATE/TIME Number of incident reports Incident reports categorized

34 Percentage of children and neonate medication incidents by type of medication incident (NPSA 2009)

35 ep Benefits - other Able to view medications from previous admissions/op appointments Reduction in time wastage No drug chart searches Electronic ordering of non-stock items from pharmacy possible Reporting Antibiotic audits, CQUINS & QIPP targets, analgesics prescribed, CIVAS TTAs for GPs clear & unambiguous

36 Conclusions Software functionality has achieved the initial aim (to replace the paper drug chart) Clinical benefits have been achieved Contract-defined developments required to achieve further benefits, complete user acceptance and to enable implementation in complex areas Continued study required into clinical benefits of ep for paediatric patients

37 Acknowledgements