focus Medicatio Maagemet Safely Automatig the Medicatio Use Process Not as Easy as It Looks By Dave Troiao, RPh; Julie Morriso, RN; Frak Federico, RPh; ad David Classe, MD Keywords Computerized provider order etry, closed loop medicatio maagemet, medicatio, safety, adverse drug evet, sequece, implemetatio, dispesig, admiistratio. Abstract The medicatio use process is oe of the most complex ad risky cliical care processes i the hospital. It ivolves a large umber of caregivers i widely diverse areas: physicias, urses, pharmacists ad respiratory therapists. Studies performed over the past several years have show that medicatio errors ad adverse evets occur i all parts of the medicatio use process. Techologies are available to improve medicatio safety across the etire medicatio use process, but implemetatio ca be expesive, itrusive ad complex. To gai the beefits from various techologies, orgaizatios must cosider how the iterplay betwee these techologies affects the workflow ad how best to implemet these techologies. Our approach for plaig for these implemetatios alog with a suggested sequece will be discussed i this article. The medicatio use process is oe of the most complex ad risky i the hospital. It ivolves a large umber of caregivers i widely diverse areas: physicias, urses, pharmacists ad respiratory therapists. Studies performed over the past several years have show a high icidece of patiet harm caused by medicatio errors ad adverse drug evets i all parts of the medicatio use process (e.g., orderig, trascribig, dispesig ad admiistratio). Hospitals have attempted to remedy this situatio through sigificat ivestmets i techology, however, the icidece of prevetable medicatio errors ad adverse drug evets remais uacceptably high. Oftetimes, the techology implemeted is drive by a departmet or i respose to a serious evet, with little uderstadig of the overall impact ad complexity itroduced whe the solutio is ot evisioed as part of a whole system. Also, there must be a uderstadig that techology will ot be effective uless there is a culture that embraces reduced variatio ad a multidiscipliary approach to the medicatio use process. MEDICATION USE WITH SUPPORTING TECHNOLOGIES The medicatio use process is widely recogized to iclude the key steps ad activities outlied below, all of which must work i cocert to esure efficiet ad effective medicatio therapy. Each of these steps is beset with challeges that orgaizatios must address through policy chages, process redesig ad techology implemetatios. The opportuities for prevetable adverse drug evets (ADE) withi each of the steps of the medicatio use www.himss.org volume 23 / umber 4 FALL 2009 jhim 17
process are well uderstood, with those percetages highlighted below. Techologies are available i all parts of the medicatio use process which have bee show to sigificatly reduce patiet harm associated with medicatio errors. May orgaizatios have implemeted some or all of them with varyig degrees of success. History Takig Obtaiig ad documetig medicatio history: Challege Iability to completely idetify home medicatios ad separate true allergies from other sesitivities. Recocilig medicatios at admissio: Challege Medicatios are ofte ot completely recociled for hours or eve days after a patiet is admitted ad admittig orders have bee writte. The recociliatio process is time cosumig eough to demotivate prescribers from performig it, especially specialists who have limited experiece with rage of medicatios a patiet may be takig. The followig techologies have proved effective at addressig the challeges i the history-takig process, whe coupled with a orgaizatioal focus o multidiscipliary cliical workflow redesig, a drive toward reductio i care variatio ad chage maagemet. Electroic home medicatio prescriptio iquiry: Provides complete home prescriptio iformatio from isurace compaies, PBMs ad exchages electroically. Electroic medicatio recociliatio: Electroic mechaism to support the review of home medicatios ad facilitate orderig/reorderig at admit, discharge ad chage of level of care. This techology also may provide the beefit of icorporatig the medicatio recociliatio process ito the orderig process, which makes the performace of the task more palatable ad less time cosumig for providers. Orderig ad Trascribig Forty-ie percet 1 of prevetable ADE s occur i prescribig, ad 11 percet 1 occur i trascribig. Therapeutic decisio makig: Challege Providers have icomplete patiet iformatio o which to make therapeutic decisios. Medicatio orderig: Challege Provider orders are illegible ad do ot cotai all of the iformatio eeded by departmets to perform ordered therapies ad diagostics. Providers do ot always promptly order all related orders (e.g., drug levels whe a drug with a arrow therapeutic rage is ordered.) Submissio of paper orders ad trascriptio ito a dispesig system: Challege Distributio of paper orders is slow; ad orders are easily misplaced ad must be re-etered ito the pharmacy system. The followig techologies have proved effective at addressig the issues with the orderig ad trascribig processes, whe coupled with a orgaizatioal focus o multidiscipliary cliical workflow redesig, a drive toward reductio i care variatio ad chage maagemet. CPOE with cliical decisio support: Provider etry of orders with decisio support facilitated by robust electroic order sets. Decisio support icludes drug iteractio checkig (drugdrug, drug-allergy, etc.); scree ad field checkig of values for appropriateess; ad alerts which suggest additios or chages to therapy based upo patiet parameters, lab values ad other orders. Withi the cotext of a complete electroic health record which provides more complete iformatio to the physicia, CPOE results i more complete ad therapeutically appropriate orders which are trasmitted electroically ito departmetal systems (e.g., radiology, laboratory, pharmacy) rapidly ad with the elimiatio of trascriptio or re-etry of orders. Research has show that up to 50 percet 2 of ADE s are elimiated from the prescribig process ad up to 72 percet 2 are elimiated from the trascribig process through the appropriate use of CPOE. Medicatio Procuremet Selectio/maagemet of formulary: Challege Agreemet of medical staff to a formulary ad eforcemet of limited use of o-formulary items. Purchasig: Challege Substitutios of oe maufacturer s product for aother due to availability from the wholesaler or savigs opportuities meas that a variety of brads is stocked for may items. Maagemet of medicatio ivetory: Challege Difficulty maitaiig appropriate levels of medicatio stock i the multitude of areas where medicatios are stocked. Icorrect stockig of automated dispesig devices or other storage locatios. The followig techologies have proved effective at addressig the issues with the medicatio procuremet process, whe coupled with a drive toward reductio i care variatio ad chage maagemet. Electroic supply chai tools. Maiteace of perpetual ivetories withi dispesig areas icludig automated dispesig machies, which facilitate electroic medicatio purchasig. The use of bar codes for ivetory maagemet facilitates the maiteace of the perpetual ivetory ad provides safeguard at all steps of the stockig process. Pharmacy Maagemet Fourtee percet of prevetable ADEs occur i dispesig. 1 Evaluate ad verify order: Challege Sigificat lag time betwee order ad availability of medicatios. Select medicatio for dispesig: Challege Not all medicatios are labeled with readable bar codes from the maufacturer. Prepare medicatio: Challege Errors i preparatio of IVs ad lack of uit dose for odd doses(e.g., ½ tabs). Dispese/distribute medicatio: Challege Errors i dispesig related to; wrog medicatio, wrog dose, icorrect labelig. The followig techologies have proved effective at addressig the issues with the pharmacy maagemet process, whe coupled a focus o multidiscipliary process improvemet with a drive toward reductio i care variatio ad chage maagemet. Automated dispesig systems. There are two basic categories of dispesig devices: those that support cetralized (from the pharmacy departmet) dispesig ad those that support decetralized (at or ear the poit of care) dispesig. These sys- 18 jhim FALL 2009 volume 23 / Number 4 www.himss.org
tems are typically itegrated with the pharmacy departmetal system to receive orders ad exchage cart fill lists. Typically, carousels ad robotics are used withi a cetralized area ad automated dispesig machies (ADM) or locked cabiets i patiet rooms are used i decetralized dispesig. ADMs ca use bar codes o medicatios to esure that the medicatios are placed i the proper locatio withi the devices. All systems ca reduce the mapower required for dispesig activities. Medicatio repackagig ad labelig with barcodes. Devices that are used to re-label ad repackage medicatios with bar codes i either stadard or patiet specific packages. I some cases these devices are used to repackage all medicatios, eve those which ca be purchased with bar codes, i others just those which caot be purchased with readable bar codes. This techology also allows for medicatios to be repackaged ito patiet specific doses which are ot commercially available (e.g. ½ tab) reducig the complexity durig medicatio admiistratio. There are two types of devices to help with this; simple stadaloe tabletop re-packagig/re-labelig devices that are used to periodically repackage batches of medicatios, ad sophisticated real-time dispesig/re-packagig/re-labelig devices that store 100 to 500 medicatios ad repackage them i patiet-specific packages as eeded for first dose ad ogoig dispesig. Research has show that up to 97 percet 3 of ADEs ot addressed by BCMA, are elimiated i the dispesig process through the appropriate implemetatio of bar code dispesig techologies. Admiistratio Maagemet Twety-six percet of prevetable ADE s occur i Admiistratio. 1 Educate ad egage patiet/family: Challege Varyig Eglish laguage proficiecy ad educatioal levels make educatio difficult. Select medicatio ad trasport to the poit of care: Challege Curret order iformatio ad medicatios are ofte ot readily available at or ear the poit of care. Admiister medicatio: Challege Dosig calculatios ca be made i error whether simple (e.g. 1/2 tab=150mg) or complex ifusio rates calculatios. Documet admiistratio ad related iformatio: Challege Documetatio of admiistratios is ofte icomplete ad/or ot completed i a timely maer. Documetatio of admiistratios is doe o differet records i differet systems so a comprehesive record is ot ready available to all caregivers. Assess ad moitor respose: Challege Documetatio of assessmet ad patiet respose is doe o differet records i differet systems so a comprehesive record is ot ready available to all caregivers. Follow-up moitorig of medicatio effectiveess (e.g., pai score) is ofte delayed or overlooked etirely. The followig techologies have proved effective at addressig the challeges with the medicatio admiistratio process, whe coupled with a orgaizatioal focus o multi discipliary cliical workflow redesig, a drive toward reductio i care variatio ad cliical chage maagemet: Electroic medicatio admiistratio record with bar code medicatio admiistratio. emar provides a up to date electroic record of medicatio orders ad admiistratios ad other relevat iformatio (e.g., lab values) that ca be used at the poit of care. BCMA provides checkig of doses ad timig of admiistratios at the poit of care supported by bar codes to esure all of the rights are accurate ad facilitates the documetatio of medicatio admiistratios. The medicatio use process is oe of the most complex ad risky cliical processes i the hospital. Smart pumps. Advaced ifusio pumps which provide safeguards for IV admiistratio icludig bar code readers ad limits to ifusio rate rage etries. The most sophisticated are itegrated with the medicatio orders for checkig purposes ad to receive order iformatio, ad emar ad I&O to elimiate duplicate documetatio tasks i these systems. Research has show that up to 70 percet 4 of ADEs are elimiated from the dispesig process ad up to 13 percet 4 are elimiated from the admiistratio process through the appropriate use of BCMA. Likewise, smart pumps have bee show to reduce up to 37 percet 4 of prevetable admiistratio ADEs. Quality Assurace Self-reportig of medicatio icidets: Challeges Lack of automated iformatio requires time cosumig maual data collectio. Less tha 10 percet of all medicatio icidets are reported by self-reportig systems. Icidets are gathered from multiple sources (e.g., self-reportig, retrospective review, coded errors) ad are ot easily compared or aalyzed together to idetify treds. Ofte the reported icidets are ot researched i a timely maer after the occurrece ad it is difficult to gather iformatio whe time has passed. Surveillace for ADEs (Cocurret ad Retrospective): Challege Lack of automated iformatio requires time cosumig maual data collectio ad aalysis. The followig techologies have proved effective at addressig the challeges with the medicatio quality assurace process whe combied with a focus o drivig a culture of quality ad chage. Automated ADE surveillace. These systems provide a cocurret ad retrospective review of orders, lab values ad other cliical data which ca idetify potetial adverse drug evets. Review by a traied cliicia is required to positively idetify whether a ADE has occurred. They ofte idetify ADEs that are ot reported by self-reportig systems. Med evet self-reportig ad aalysis systems. Electroic self-reportig systems ca esure that critical iformatio is collected whe the report is made ad ca facilitate aalysis of medicatio evets. COMPREHENSIVE MEDICATION SAFETY APPROACH Implemetatio of the techologies outlied i the previous sectio ca be expesive, itrusive ad complex. I order to gai the beefits from them, the implemetatio requires orgaizatioal commitmet with extesive user iput to chage work processes as well as the wise use of a rage of supportig tools (e.g., sca- www.himss.org volume 23 / umber 4 FALL 2009 jhim 19
Fig. 1: Activities performed followig the developmet of a comprehesive medicatio safety strategy. ers, hadheld devices, mobile carts). I additio, orgaizatios must carefully cosider how the iterplay betwee these techologies affects the workflow ad how best to stepwise implemet these techologies to drive toward a safer medicatio use process. Our experiece with these issues has show that a comprehesive strategy to medicatio safety that itegrates both process ad techology i a overall pla is the safest approach to this complex problem. We believe that the followig priciples are key to the successful implemetatio of these techologies: Strog cliical ad executive leadership to drive chage. The etire medicatio use process must be cosidered, ot just the particular pieces beig affected by the techologies beig cotemplated for implemetatio. A uderstadig of the curret state, techologies, ad processes is required to idetify risks ad stregths i the curret medicatio use process prior to ay plaig ad ultimate desig. A shared visio of what the ultimate medicatio use process will look like ad its impact o all ivolved cliicias must be developed prior to the implemetatio of these techologies ad should drive ay plaig efforts. A focus o cliical chage maagemet, icludig commuicatio. Uified desig must be performed which icludes the iformatio system, work processes, correspodig policies, ad supportig techologies. This uified desig must be performed by a multi-discipliary team. Extesive desig ad implemetatio plaig reduces the risk of adverse outcomes ad false starts i the implemetatio process. Appropriate ifrastructure must be i place to support rapid commuicatio ad itegratio amog systems. Orgaizatioal commitmet to dedicatig resources to esure full implemetatio. The developmet of a comprehesive medicatio safety strategy is accomplished through the performace of the followig activities: Curret state defiitio. The purpose is to determie how well a orgaizatio may respod to curret ad future efforts to create ad sustai chage ad to support plaig for the chage effort. The curret state defiitio requires a uderstadig the followig: What steps are performed ad by whom? What are the coectio poits ad hadoffs? What parts of the process work well ad what parts do ot? What techologies are used ad how does iformatio flow? Leadership aligmet also is importat to gauge as processes cross orgaizatioal boudaries. It is importat to assess risks, commuicate the strategy ad receive commitmet early o from key leaders. A chage readiess assessmet tool ca be used to evaluate curret practices ad help the orgaizatio pla for ad maage the chage effort. Visioig. Establishig a visio for the future medicatio use process will help to clearly defie what the future state eviromet will look like for all stakeholders. This is a critical step that is ofte overlooked by orgaizatios as they begi process improvemet iitiatives. The operatioal chages are sigificat ad ofte times difficult for the stakeholders to fully uderstad prior to the actual implemetatio. Creatig a visio ot oly forms the highest level road map, it also geerates a shared directio ad mometum amogst the participatig stakeholders ad orgaizatioal leaders. This shared visio of the future eterprise focuses the orgaizatio o achievig the desired future state rather tha just correctig what is wrog with the preset state. The eterprise visio should be a brief but compellig documet depictig what the eterprise will be like i the future oce the process improvemets have bee accomplished. It is most effective ad will be best uderstood by a broad rage of costituets whe it icludes a arrative descriptio, pictures ad scearios, expected beefits ad success measures. The idetificatio ad clarificatio of goals, objectives ad expected value/beefits is essetial to the success of ay project. The orgaizatioal future state exists to support the achievemet of cliical chage goals, objectives ad priorities. A set of guidig priciples will eed to be agreed upo, documeted ad validated i order to provide the proper executive guidace to those ivolved i the iitiatives as they prepare to make decisios about process, workflow, ad system cofiguratios. Guidig priciples are the ideals ad busiess rules established by the orgaizatio to help meet strategic goals ad objectives. Uified desig. The purpose of this activity is to coduct a itegrated, multidiscipliary redesig of curret processes ad to idetify required chages to system set-up, techologies, policies ad curret practices that will drive the implemetatio of medicatio safety ehacemets. The results from the curret state assessmet are evaluated with recommedatios for the future state visio durig a series of desig sessios i this phase to determie the future state i the desig sessios. We geerally suggest brigig future state recommedatios/ best practice to the group for discussio, rather tha attemptig to orgaically develop future state from a blak slate i the desig sessios. 20 jhim FALL 2009 volume 23 / Number 4 www.himss.org
Table 1: Geeral iformatio o techology implemetatio. scope; project staffig/resource requiremets; project goverace ad structure; risk mitigatio/cotigecy model; chage maagemet pla; techology requiremets; timelie; budget; ad beefits realizatio pla. This uified desig process looks at process, practice, techology cocurretly ad is multidiscipliary. We recommed the use of a combiatio of process maps, prototypes for potetial improvemets, discussio regardig the impacts of curret deficiecies or areas for improvemet ad a drive toward cosesus o chages to the process, techology ad staff roles. Plaig. The purpose of this activity is to do prelimiary plaig for the techology implemetatios. The Implemetatio Pla should iclude sequecig ad coversio requiremets ad project IMPLEMENTATION APPROACH Implemetatio of these techologies will result i a closed loop medicatio maagemet process (CLMM). This CLMM process whe desiged ad implemeted properly is the safest approach to medicatio use which is curretly available. It will likely take several years ad tes of millios of dollars to implemet i a typical hospital. It is critical that a pla be developed, aroud the phasig of the techology implemetatios, which esures that techology supports how cliicias work ad does ot dictate processes that lead to dagerous workarouds. The plaig should also take ito accout: Implemetatio ad maiteace staffig. Impact of iterim states o staff workload. Capital ad operatig budgets. Impact of competig iitiatives. Medicatio safety risks of the iterim states. Ease of implemetatio of the techologies. Time eeded to implemet each of the techologies. Curret state of techology implemetatio ad techology ifrastructure required to support the future state. Maturity of software from selected techology vedors(core HIS vedor). The table below cotais a listig of geeral iformatio o implemetatio: time, level of difficulty, cost ad ay predecessors of the major techologies used to improve medicatio safety for a typical mediumsized hospital with the required level of focus ad commitmet: While there is o idustry best practice aroud the sequecig of the implemetatio of IT i the medicatio use process, the suggested sequece outlied below is the result of our experiece i assessig ad assistig hospitals to reduce errors ad harm associated with the medicatio use process. Each hospital must examie its ow medicatio system, culture ad available resources whe decidig o techology implemetatio roll out approach. The suggested sequecig outlied is for a ideal hospital i a clea-slate positio, which is a hospital with oe of these techologies, whose sole focus is medicatio safety. The techology sequecig depicted i Figure 1 would eable a orgaizatio to take advatage of the optimal medi- www.himss.org volume 23 / umber 4 FALL 2009 jhim 21
Fig. 2: The techology implemetatio sequece. catio safety beefits that these techology implemetatios ca provide. The techology implemetatio sequece discussed below with a brief explaatio of its place i the sequece. Pharmacy departmetal IS. This is the fudametal system which liks the disparate systems ad techologies together i the medicatio use process. It is used as the hub with iterfaces to them, eve i the presece of a CPOE system. The pharmacy system is much more product based tha the CPOE system so it more easily liks to the various dispesig devices ad other systems. Smart pumps. The sigificat impact i reducig IV ADEs puts this high o the list of med safety techologies. I its simplest form the libraries i the pumps reduce the likelihood that harmful ifusio rates will be set. The more advaced fuctioality orders ad documetatio iterfaces are just begiig to come available ad will lead to a icrease i medicatio safety. emar. This has the potetial to have a dramatic impact o the admiistratio process by providig up to date order ad admiistratio iformatio to all providers. It is a atural by-product of the order etry ad maagemet i the pharmacy system so ca be trasitioed to from a paper MAR without great difficulty either whe a pharmacy system is implemeted or at ay time after. Automated supply chai tools. These tools for purchasig ad ivetory maagemet will ot have much direct impact o medicatio safety, except whe bar codig is used to stock the ADMs ad other storage locatios. Med re-packagig ad re-labelig with bar codes. At a miimum this is a ecessary batch fuctio to esure that all medicatios have readable bar codes o them to support bar code based dispesig ad admiistratio. More sophisticated versios provide a combiatio of repackagig ad dispesig fuctios. Medicatio evet self-reportig ad aalysis systems. This is usually a stad-aloe system which provides iformatio o med icidets which ca provide valuable isights ad lead to chages which ca improve med safety. It is a fudametal techology. Automated ADE surveillace. This more sophisticated approach to idetifyig adverse drug evets works i tadem with self-reportig ad is a very simple, low-cost way to expad the kowledge of medicatio issues. It does require that a sigificat amout of cliical data be available olie. ADM (decetralized). These are used by most hospitals to dis- 22 jhim FALL 2009 volume 23 / Number 4 www.himss.org
pese betwee 20 percet ad 90 percet or more of medicatios (excludig large-volume IVs). There is ot a lot of evidece that this techology has a sigificat impact o medicatio errors, but it does make medicatios, especially first doses more rapidly ad readily available. Whe coupled with bar code techology for stockig ad removig medicatios from these devices some improvemet of medicatio safety ca be achieved. Dispesig carousel (cetralized)/dispesig robotics (cetralized). The appropriate combiatio of cetralized ad decetralized dispesig techologies is a difficult balace to achieve. I geeral, med safety is ehaced through icreased cetralized dispesig rather tha high volume of decetralized dispesig. These techologies provide the tools for pharmacy to take o the load of cetralized dispesig while holdig staffig ad service (e.g., delivery times) levels costat. BCMA with positive patiet ID. This techology is extremely effective i elimiatig admiistratio errors. It is extremely complex ad expesive to implemet, requirig sigificat chages i the dispesig, storage ad admiistratio processes, as well as a sigificat ivestmet i supportig techologies such as mobile medicatio carts, PCs, scaers ad bar-code labelig. It is most successfully implemeted after a high degree of cetralized dispesig is implemeted. CPOE. Despite beig a highly effective mechaism for reducig orderig ad trascribig errors, CPOE is ear the ed of this list due to its high degree of difficulty. It requires that a robust EMR is i place so that the vast majority of cliical iformatio is available olie. It is especially difficult for hospitals with a idepedet medical staff to achieve a high degree of CPOE use otherwise. Whe a lower level of CPOE use is preset, a complex ad dagerous hybrid orderig/trascribig system is ecessary. It is this risk of ieffective or partial implemetatios that moves this techology to this poit o the list. A geeral rule of thumb is that the more iformatio that is olie, the more likely it is that physicias will get olie ad use the system, icludig for CPOE. It has become icreasigly clear, from a safety perspective, that implemetig CPOE before a pharmacy system, BCMA ad emar are i place creates high-risk workflows that have bee show to ultimately icrease the risk to patiets. Med recociliatio. This techology is highly effective i reducig the risk of medicatio errors, whe doe cosistetly ad carefully. It is ideally implemeted with or slightly after CPOE so that it ca be itegrated ito the orderig workflow. I that situatio the physicia workflow is miimally disrupted ad so the likelihood of a successful implemetatio is icreased. We recommed that ay techology selected should be tested to determie if it achieves the desired fuctioality. If the techology is ot well desiged ad implemeted, users will develop workarouds that ca lead to ew errors. OTHER CONSIDERATIONS The America Recovery ad Reivestmet Act (ARRA) of 2009 provides a commadig $30 billio for the adoptio ad use of health IT by Medicare ad Medicaid providers over the ext 10 years. To receive the fiacial icetives, eligible hospitals must make Meaigful Use of the HIT. It is expected that the federal icetive programs, drivig healthcare provider orgaizatios will icrease the push for CPOE. The defiitio of meaigful use will likely impact that push toward CPOE to be a part of a larger health IT strategy, icludig the medicatio-use process to address aticipated requiremets for key medicatio safety compoets such as: medicatio recociliatio, CPOE, a robust CDS tool set, itegrated emar with bar codig ad a pharmacy system itegrated with CPOE ad emar. Factors comig out of the fializatio of ARRA may create other icetives that play ito the ultimate establishmet of a implemetatio pla for provider orgaizatios. JHIM David Troiao, RPh, MSIA, Pricipal, leads the medicatio safety cosultig practice at CSC. He is focused o performace improvemet i all aspects of the medicatio use process. Julie Morriso, RN, Pricipal with CSC, a leadig global cosultig ad systems Itegratio compay, where she cosults with provider orgaizatios to select, pla for ad implemet advaced cliical iformatio systems. Frak Federico, RPh, Executive Director for Strategic Parters, ad safety faculty at the Istitute for Healthcare Improvemet. His primary areas of focus iclude patiet safety ad reliability priciples i healthcare. David Classe, MD, MS, Seior Parter at CSC, leads safety ad quality healthcare iitiatives. He is a Associate Professor at the Uiversity of Utah ad a Active Cosultat i Ifectious Diseases at the School of Medicie. Refereces 1. Bates DW, et al. Icidece of adverse drug evets ad potetial adverse drug evets. JAMA. 1995;274:(1)29-34. 2. Assumes that 80 percet of physicias will adopt CPOE; for adoptig physicias 90 percet of orders will be placed electroically ad 70 percet of recommedatios will be followed equals 50 percet impact o prescribigrelated ADEs. Sice CPOE virtually elimiates trascriptio errors for those orders placed by physicias the impact would be 80 percet x 90 percet = 72 percet. 3. Poo, et al. Medicatio dispesig errors ad potetial adverse drug evets before ad after implemetig bar code techology i the pharmacy. A It Med. 2006;145:426-434. 4. Product value aalysis: smart ifusio systems. Thompso ad Classe; FCG 2005 www.himss.org volume 23 / umber 4 FALL 2009 jhim 23