In the decade between 1996 and 2006, US emergency department (ED) visits grew by 32% to nearly 120 million visits per year,1 while the total number of emergency care providers declined. Flagging supply and growing demand created a crisis of overcrowding that persists today. EDs have become akin to mini hospitals, offering emergent care, primary care, and boarding ill patients who wait for scarce inpatient beds. Amid these chaotic conditions, few safeguards have evolved to address the mounting risks to medication safety. Twice as many medication errors occur in EDs than in the inpatient setting.2 Of the approximately 110 million patients who receive ED care each year in the United States,3 5% experience adverse drug events4; 70% of these events, or 3.8 million, are thought to be preventable.5 In fact, the Institute of Medicine reported that EDs have the highest rate of preventable adverse events among clinical environments studied.6,7 Yet, the rate at which medication errors are intercepted prior to administration is lower in EDs than in the rest of the hospital (23% vs 39%).
Medication administration and prescribing most often are reported as the steps of the medication use process in which ED errors originate.2 One study found that 1 of every 2 doses prescribed in the ED involved an administration error; 14% of these errors were considered at least moderate in clinical severity.8 In response to the elevated risk, the health-system pharmacy community is seeking systematic changes to prevent medication errors in EDs, with a specific focus on the medication administration and prescribing steps.
Closing the Loop
In a closed-loop medication administration system, physicians have access to patient-specific information and clinical decision support tools at the time they are ordering medication. Additionally, pharmacists can view the same information and review the orders, and nurses, at the moment of medication administration, can verify the medication order with respect to the “five rights” (patient, drug, dose, route, and time). A closed-loop system also ensures that each dose is documented accurately at the time of administration, thus adding information to the patient’s electronic medication administration record (eMAR) for informed subsequent clinical decision making.
In current practice, the redundancies inherent in the closed-loop medication management approach do not commonly exist in EDs. One analysis of wrong-dose events in EDs showed that 28.5% of the events implicated missing patient information errors (eg, weight, age, existing medication profiles, medication reconciliation process, and wrong patient identification). Dosing errors also are a good example of a risk that exists in EDs when independent double checks are not performed.
A closed-loop medication safety solution for the ED has multiple components. To start, a number of no-tech solutions, such as limiting the number and variety of medications and concentrations available in EDs, can immediately improve safety.9 Also, involving clinical pharmacists in EDs has the potential to reduce errors. Although the presence of clinical pharmacists in the inpatient setting has long been recognized as resulting in safer and more effective use of medications,10 pharmacists based in the ED are relatively rare. Fewer than 7% of hospitals have ED-based pharmacists,11 despite the Joint Commission’s Medication Management standard 4.10 and an endorsement from the American Society of Health-System Pharmacists specifying the benefit of pharmacists’ prospective review of medication administration in the ED.12,13 The primary obstacle to the widespread establishment of clinical pharmacy services in the ED may be financial. No definitive scientific assessment has been published to support the cost–benefit of such programs.
Staffing aside, computerized prescriber order entry (CPOE) and eMAR supported by assistive technologies such as bar-code medication administration (BCMA) provide substantial opportunities for improved medication safety. Both present significant, although not insurmountable, challenges that make it necessary to carefully weigh the merits and costs of each solution when designing a long-term plan for medication safety improvement in EDs. Recognizing that both will be required eventually, the order in which organizations introduce solutions will affect their speed to success.
CPOE implementation in the ED can reduce pharmacy verification times by up to 80%, and can reduce test repetition, documentation redundancy, and length of stay.14,15 Initially, the proposed rules of the American Recovery and Reinvestment Act of 2009 excluded ED orders in calculating CPOE usage. But after insistence from health care providers, the Final Rule for Stage 1 meaningful use specifies that more than 30% of all unique patients admitted to eligible “inpatient or emergency departments” must have at least one medication order entered using CPOE.16
eMAR and Bar Coding
Since the mid-1990s, hospitals have demonstrated that eMARs with assistive technology such as BCMA can improve medication safety, enhancing the effectiveness of double checks.17,18 A 2011 ASHP survey found that 50% of hospitals used BCMA.19 As the adoption of BCMA grows, however, the literature advocating its use has been focused primarily on inpatient units and not EDs.
Some long-time users of BCMA technology in the inpatient environment contend that the technology is not appropriate for use in EDs, citing numerous obstacles such as patient wristbanding and the complexity of affixing bar codes to the wide range of medication dosage forms administered to patients in EDs. Even facility issues such as inadequate wireless infrastructure, electrical sources, and a lack of physical space for scanning equipment can hinder BCMA adoption in the ED. Furthermore, ED staff members often initially do not recognize the value of scanning, creating compliance issues and pushback. Additionally, ED staff may express concern that scanning will delay the administration of urgently needed medications, impede clinical care, and lengthen ED turnaround times.
Yet the greatest challenge to BCMA in EDs is the absence of an electronic health record (EHR). According to a study in 2010, 53.5% of EDs still operate without clinical information systems.20 Essential for bar-code scanning systems, software must compare the medication dose to be administered with an electronic order. In EDs, medications often are prescribed verbally and administered immediately, departing from the inpatient best-practice cycle of physician order, pharmacist review, dispensing, administration, and documentation. Circumventing the pharmacy review process interrupts the standard workflow required by BCMA systems.
Although it is preferable that medications be matched to physician orders before being administered, even in the absence of a pharmacy review, BCMA at least can confirm which medication caregivers have taken from automated dispensing cabinets, providing a double check. Additionally, ED BCMA systems may provide basic drug-specific dose-range checks and warnings from embedded drug reference libraries. When interfaced with hospital information systems, BCMA systems may provide patient-specific allergy checking and weight-based dose calculations. Furthermore, ED eMARs enable point-of-care access to drug information, protocols, order sets, and standardized emergency drug preparation guidance, as well as references regarding the rate of administration or infusion, method of titration, and so on.21,22
Another benefit of BCMA is improved documentation. Scanning medications in EDs helps ensure the creation of a complete and accurate record of all medications administered to a patient during his or her hospital stay. This is invaluable to physicians when deciding to continue, discontinue, or amend medication orders. Indeed, prospective pharmacy review is the end goal, but until that is in place, a bar code–enabled eMAR provides the best possible information for retrospective review by pharmacy. Even when EDs are not seamlessly integrated with EHRs throughout the rest of the hospital, accurately printed eMARs derived from ED BCMA systems can follow patients for safer transfers and improved continuity of care.
Additional safety and efficiency can be gleaned through implementation of the newest frontier of medication administration safety—integration of eMAR and BCMA with “smart” infusion pump programming or bar code–enabled IV (BCIV). In an emergent situation, the nurse relies on memory and limited notes to retrospectively document the infusions administered, a time-consuming process. However, with BCIV, the infusion data, titrations, and time stamps are captured on the pump throughout the episode as the nurse scans through each infusion. The system associates the information with physiologic and hemodynamic data from cardiac monitors. The nurse can quickly review the synched data, revise it if necessary, and sign the electronic record, reducing post-code documentation time to just minutes.
A Step in the Right Direction
Notwithstanding the potential for clinical pharmacists to someday provide prospective medication order review in the ED, the next level of safety improvement requires broader, more complicated solutions that will be accompanied by hefty price tags and complex human factors issues. Despite the special requirements of emergency care, the path to safer medication administration in the ED ultimately must take a facility through the journey of CPOE and eMAR supported by assistive technology. As briefly touched on here, these projects present a host of operational challenges for the ED and require significant financial investment. Because addressing all of them at once is implausible, decisions must be made regarding where to begin. The current states of information technology infrastructure in individual organizations will be a determining factor, but given the relative costs and user-compliance hurdles that accompany CPOE relative to eMAR with bar coding, BCMA may offer greater opportunity than CPOE for rapid safety improvement.
Jamie Kelly is the president of Entropy Research, Inc, a marketing firm serving
the life science industry. Ms. Kelly is the
co-founder of the annual unSUMMIT for Bedside Barcoding educational conference
(www.unsummit.com). She may be contacted at firstname.lastname@example.org.