Workflow in Administering Medications
By Nursine S. Jackson, MSN, RN
The following article is an excerpt from the upcoming book, “Walking Audit Trails and Exploring EMRs,” pending publication in 2022.
Medication administration and reconciliation is a historically high-risk area in which examination of workflow, as a matter of routine, has improved care. To wit, medication errors have been significantly reduced because of data analytic processes provided using electronic health records.
There are many steps in the workflow involved in medication administration, and an interruption in workflow leading to medication error can occur at any step along the way.
Even before a medication is ordered, a medication reconciliation must be performed to ascertain the patient’s current medications, doses, frequencies, and routes of administration. Only after this first step is completed should the physician enter an order via Computerized Physician Order Entry (CPOE), so she has the best opportunity to create a safe and appropriate medication order. The order is then conveyed digitally to the pharmacy.
Order History Audit Trail
There are many audit trails within the software systems. As such, the Order History has its own audit trail that will show the who/what/when of writing the physician’s order and sending it to the pharmacy. Once the order reaches the pharmacy team, the Order History will record who received the order, filled it, checked to verify that it was properly filled and that there are no contraindications warranting further scrutiny and possible modifications of the medication order. This Order History can be obtained by requesting its production using the identifying number on the computerized order.
Medication Cabinet Audit Trail
After this workflow, the ordered medication is stocked into the medication cabinet. The medication cabinet is governed by a rather sophisticated computer on board that automates and records activities surrounding medication administration. It may be called automated dispensing cabinet (ADC), automated dispensing devices (ADD), or automated dispensing machines (ADM). Medication cabinets have their own integral softwares that will collect data about when the medication was stocked, when it was accessed, by whom, for whom, etc. In a facility utilizing barcoding, the nurse may gain entry with a fingerprint, that will open the patient’s drawer to access the medication. She then scans the barcode on the label of the medication package. Before administering the medication she will scan the patient’s wristband and her own name tag, which results in collecting additional data about the steps involved in the medication administration.
This automated data collection process expedites charting in the patient’s Medication Administration Record.
If the medication is to be administered intravenously, the software within the infusion device used to deliver the fluids will also record additional data. This data may include the unique identifier of the infusion device, when the medication was hung, by whom, how much fluid was in the bag, how much infused, rate of infusion, alerts that went off, etc.
If a nurse has to override software alerts to gain access to the medication, the override data will be preserved.
Data in Routine Business Processes
As illustrated, the medication administration workflow has many steps that generate a lot of data, which is collected and preserved in the routine course of patient care. Hospitals routinely utilize this data to generate reports that allow for the internal analysis of the workflow. They want their staff to be as efficient as possible and billing to be accurate. This data should also be used to enhance safe medication administration.
Evidence of problems warrant immediate scrutiny by a facility – problems like when a series of medication errors has occurred, when a pattern of late administration of medications is noted on a unit, and especially when a medication-related sentinel event has occurred. When a medication error has resulted in patient injury, the legal team should inquire as to whether an internal investigation occurred. The information obtained in the root cause analysis and the remediation should be discoverable in a system that truly wants change and improvement, as demonstrated by the results achieved by the airline industry when their investigations became transparent. However, in medicine safety investigations are too often “privileged”, i.e., not accessible, to even the patient who was injured, even when the information gained may help him with future care.
Learning that a facility failed to investigate a sentinel event speaks poorly for a facility who is a defendant in a case, and data obtained may be discoverable even when the details of investigation itself is protected. Whether this can be used as evidence, or whether the facility is at risk for penalties from a local safety authority is locality dependent.
In the best-case scenario, each error involving workflow issues would be analyzed internally then reported to a safety organization for a full analysis. Safety organizations would analyze multiple patients’ data to develop a remediation plan to prevent future errors of a similar nature. All EMR Users should care to invest in the remedies prescribed for a real or potential risk in the workflow.
Remember, preserving this workflow data is not just a nicety; it is a statutory mandate, as is giving the patient access to his data. Audit data from softwares employed in medication administration can afford the legal team the ability to properly scrutinize an error - but only if the legal team is able to discover which data is relevant to answer the case questions and then gain access to that data.
We now have decades of research showing that the workflow changes based on the analysis of audit data improves patient safety. When it is not used to improve safety on the front end, it can be used as evidence in a legal case to demonstrate errors that could and should have been prevented had a facility improved their workflows. After every medical error, whether or not the error resulted in injury, workflow should be tailored to prevent recurrent events in the future.