Implementation of an Electronic Medication Management System in a large tertiary hospital: a case of qualitative inquiry

Closed-Loop Medication Management with an Electronic Health Record System in U.S. and Finnish Hospitals

Many medication errors in the hospital setting are due to manual, error-prone processes in the medication management system. Closed-loop Electronic Medication Management Systems (EMMSs) use technology to prevent medication errors by replacing manual steps with automated, electronic ones. As Finnish Helsinki University Hospital (HUS) establishes its first closed-loop EMMS with the new Epic-based Electronic Health Record system (APOTTI), it is helpful to consider the history of a more mature system: that of the United States. The U.S. approach evolved over time under unique policy, economic, and legal circumstances. Closed-loop EMMSs have arrived in many U.S. hospital locations, with myriad market-by-market manifestations typical of the U.S. healthcare system. This review describes and compares U.S. and Finnish hospitals' EMMS approaches and their impact on medication workflows and safety. Specifically, commonalities and nuanced differences in closed-loop EMMSs are explored from the perspectives of the care/nursing unit and hospital pharmacy operations perspectives. As the technologies are now fully implemented and destined for evolution in both countries, perhaps closed-loop EMMSs can be a topic of continued collaboration between the two countries. This review can also be used for benchmarking in other countries developing closed-loop EMMSs.

The impact of transition to a digital hospital on medication errors (TIME study)

Digital transformation in healthcare improves the safety of health systems. Within our health service, a new digital hospital has been established and two wards from a neighbouring paper-based hospital transitioned into the new digital hospital. This created an opportunity to evaluate the impact of complete digital transformation on medication safety. Here we discuss the impact of transition from a paper-based to digital hospital on voluntarily reported medication incidents and prescribing errors. This study utilises an interrupted time-series design and takes place across two wards as they transition from a paper to a digital hospital. Two data sources are used to assess impacts on medication incidents and prescribing errors: (1) voluntarily reported medication incidents and 2) a chart audit of medications prescribed on the study wards. The chart audit collects data on procedural, dosing and therapeutic prescribing errors. There are 588 errors extracted from incident reporting software during the study period. The average monthly number of errors reduces from 12.5 pre- to 7.5 post-transition (p < 0.001). In the chart audit, 5072 medication orders are reviewed pre-transition and 3699 reviewed post-transition. The rates of orders with one or more error reduces significantly after transition (52.8% pre- vs. 15.7% post-, p < 0.001). There are significant reductions in procedural (32.1% pre- vs. 1.3% post-, p < 0.001), and dosing errors (32.3% pre- vs. 14% post-, p < 0.001), but not therapeutic errors (0.6% pre- vs. 0.7% post-, p = 0.478). Transition to a digital hospital is associated with reductions in voluntarily reported medication incidents and prescribing errors.

The Impact of an Electronic Medication Management System on Medication Deviations on Admission and Discharge from Hospital

Medication errors at transition of care remain a concerning issue. In recent times, the use of integrated electronic medication management systems (EMMS) has caused a reduction in medication errors, but its effectiveness in reducing medication deviations at transition of care has not been studied in hospital-wide settings in Australia. The aim of this study is to assess medication deviations, such as omissions and mismatches, pre-EMMS and post-EMMS implementation at transition of care across a hospital. In this study, patient records were reviewed retrospectively to identify medication deviations (medication omissions and medication mismatches) at admission and discharge from hospital. A total of 400 patient records were reviewed (200 patients in the pre-EMMS and 200 patients in the post-EMMS group). Out of 400 patients, 112 in the pre-EMMS group and 134 patients in post-EMMS group met the inclusion criteria and were included in the analysis. A total of 105 out of 246 patients (42.7%) had any medication deviations on their medications. In the pre-EMMS group, 59 out of 112 (52.7%) patients had any deviations on their medications compared to 46 out of 134 patients (34.3%) from the post-EMMS group (p = 0.004). The proportion of patients with medication omitted from inpatient orders was 36.6% in the pre-EMMS cohort vs. 22.4% in the post-EMMS cohort (p = 0.014). Additionally, the proportion of patients with mismatches in medications on the inpatient charts compared to their medication history was 4.5% in the pre-EMMS group compared to 0% in the post-EMMS group (p = 0.019). Similarly, the proportion of patients with medications omitted from their discharge summary was 23.2% in the pre-EMMS group vs. 12.7% in the post-EMMS group (p = 0.03). Our study demonstrates a reduction in medication deviations after the implementation of the EMMS in hospital settings.

Implementing a New Electronic Health Record System in a University Hospital: The Effect on Reported Medication Errors

Closed-loop electronic medication management systems (EMMS) have been seen as a potential technology to prevent medication errors (MEs), although the research on them is still limited. The aim of this paper was to describe the changes in reported MEs in Helsinki University Hospital (HUS) during and after implementing an EPIC-based electronic health record system (APOTTI), with the first features of a closed-loop EMMS. MEs reported from January 2018 to May 2021 were analysed to identify changes in ME trends with quantitative analysis. Severe MEs were also analysed via qualitative content analysis. A total of 30% (n = 23,492/79,272) of all reported patient safety incidents were MEs. Implementation phases momentarily increased the ME reporting, which soon decreased back to the earlier level. Administration and dispensing errors decreased, but medication reconciliation, ordering, and prescribing errors increased. The ranking of the TOP 10 medications related to MEs remained relatively stable. There were 92 severe MEs related to APOTTI (43% of all severe MEs). The majority of these (55%, n = 53) were related to use and user skills, 24% (n = 23) were technical failures and flaws, and 21% (n = 21) were related to both. Using EMMS required major changes in the medication process and new technical systems and technology. Our medication-use process is approaching a closed-loop system, which seems to provide safer dispensing and administration of medications. However, medication reconciliation, ordering, and prescribing still need to be improved.