Closed-Loop Medication System: Leveraging Technology to Elevate Safety

Automated dispensing cabinets and their impact on the rate of omitted and delayed doses: A systematic review

Use of automated dispensing cabinets (ADCs) is increasing in hospital settings. ADCs bring various potential benefits, among which are improvements to patient safety and reduction of medication errors. A core function of ADCs is to prevent medication stock outs by triggering an order when stock is reaching low levels. A quantifiable patient safety measure is the occurrence of omitted or delayed doses, which can range in severity from being negligible, to potentially fatal. The purpose of this review is to identify and synthesise the existing evidence regarding the impact of ADCs situated in secondary and tertiary care inpatient settings, on the rate of omitted and delayed doses as a specific subsection of medication errors. In April 2024 searches were conducted in Embase, PubMed and CINAHL, with additional articles discovered through citation searching and from colleagues. A total of 375 articles were returned from the search. Nine articles met the inclusion criteria. The most common reason for exclusion was due to lack of relevance. The included papers were focused on centres which had implemented six or fewer ADCs. The studies mostly presented findings which suggest ADCs have a positive impact on the rate of omitted or delayed doses, although crucially only two papers correlated missed doses due to unavailability of medications The studies highlighted other factors which should be considered prior to the implementation of ADCs. Factors included staffing requirement, type of stock held in the cabinets, and interoperability with other systems. Studies only reported omitted or missed doses, none reported results on delayed doses. It is widely accepted that ADCs can prevent medication unavailability but there is a paucity of evidence linking the improved availability of medications through the utilisation of ADCs with the perceived impact on missed or delayed doses. Further multi-centre studies are needed to determine this causality.

Barcode and radio frequency identification utilization varied across Korean hospitals

Barcodes and radio frequency identification (RFID) are increasingly used in health care to improve patient safety. However, studies on their utilization in clinical settings are limited. This study aimed to comprehensively examine the utilization status of barcodes and RFID in Korean hospitals, recognize the effects and obstacles associated with utilization, and explore the measures to expand the applications of barcodes and RFID. A self-reported online survey was conducted in tertiary hospitals, general hospitals, hospitals, and nursing hospitals in the Republic of Korea. The survey questionnaire comprised questions on barcodes and RFID utilization status, the effect of barcodes and RFID utilization, measures to expand the utilization of barcodes and RFID, and information on respondents' demographics and hospitals. A representative from each of 23 tertiary hospitals, 101 general hospitals, 232 hospitals, and 214 nursing hospitals completed the survey (total response rate 17%). The data were analysed using the chi-square test or Fisher's exact test to determine the differences in responses based on the type and characteristics of hospitals. The tertiary hospitals had the highest utilizations of both RFID and barcodes (n = 10, 43.5%), whereas the nursing hospitals had the lowest (n = 96, 55.1%). Barcodes and RFID were most commonly used in the visits and security management domains. However, the use of barcodes and RFID in medication dispensing and administration safety was low, despite its value in improving patient safety. The hospitals recognized the positive effect of utilization of barcodes and RFID, reporting the highest frequency for the prevention of patient safety incidents (n = 79, 85.9%). Nevertheless, the cost of barcodes and RFID facility investments (n = 128, 90.3%) appeared to be the greatest obstacle to the introduction of barcodes and RFID. Hence, barcodes and RFID facility investment support (n = 133, 95.5%) were given the highest priority among the measures to expand barcode and RFID utilization in health care. The utilization of barcodes and RFID varied across the type and domain of hospitals in the Republic of Korea. Hospitals recognized the positive effects of barcode and RFID utilization. Nonetheless, all hospitals were concerned about the cost of investment and maintenance of barcode and RFID facilities as the main obstacles to utilization. Therefore, a support plan must be developed for the cost of barcodes and RFID facility investments to expand barcode and RFID utilization in health care.

Automated unit dose dispensing systems producing individually packaged and labelled drugs for inpatients: a systematic review

OBJECTIVES

Pharmacy automation is increasing in hospitals. The aim of this systematic review was to identify and evaluate the literature on automated unit dose dispensing systems (UDDS) producing individually packaged and labelled drugs for inpatients.

METHODS

The search was conducted on eight electronic databases, including Scopus, Medline Ovid, and Cinahl, and limited to peer reviewed articles with English abstracts published 2000-2020. Studies were included in the review if drug dispensing was performed by an automated UDDS where individually packaged and labelled unit doses were subsequently assembled patient specifically for inpatients. All outcomes related to UDDS functionality were included with specific interest in medication safety, cost-efficiency and stock management. Outcomes were categorised and results synthesised qualitatively.

RESULTS

664 publications were screened, one article identified manually, resulting in eight included articles. Outcomes of the studies were categorised as medication administration errors (MAEs), dispensing errors, costs and cost-effectiveness. Studies showed that automated UDDS reduced significantly MAEs of inpatients compared with traditional ward stock system (WSS), especially when UDs were dispensed patient specifically by unit dose dispensing robot. Patient specific drug dispensing with automated UDDS was very accurate. Of three different automated medication systems (AMSs), patient specific AMS (psAMS) was the most cost-effective and complex AMS (cAMS) the most expensive system across all error types due to the higher additional investments and operation costs of automated dispensing cabinets (ADCs). None of the studies investigated the impact on the medication management process such as efficiency, costs and stock management as primary outcome.

CONCLUSIONS

UDDS improved patient safety. However, automation is a costly investment and the implementation process is complex and time consuming. Further controlled studies are needed on the clinical and economical outcomes of automated UDDS to produce reliable knowledge for hospital decision makers on the cost-benefit of the investment and to support decision making.

Adopting an electronic medication administration system in long-term care facilities: a key stakeholder interview study in Macao

To improve medication safety for residents in long-term care facilities (LTCFs), electronic medication administration records (eMARs) are widely adopted in Macao. This study aimed to (1) develop a logic model for adopting eMAR in LTCFs and (2) explore the contextual factors relevant to the implementation. Semi-structured interviews were conducted with key stakeholders (managers, doctors, nurses, pharmacy staff and other frontline workers) experienced with eMAR in LTCFs in Macao between February and March 2021. Purposive sampling was used for recruitment and thematic analysis followed the theoretical framework of the logic model. All 57 participants were positive about eMAR. Financial and nonfinancial resources were critical to adopting eMAR. eMAR was mostly used for its functions in documentation, e-prescribing and monitoring. Immediate output included simplified working process, reduced errors, closer monitoring of residents' conditions, and timely communication among staff. The outcomes mainly related to efficiency, safety and quality of care, workload redundancy, and data unification. Key influencing factors included eMAR flexibility, stability, and technical support. Adopting eMARs is highly consuming and the benefits in improving quality of care can only be realized with appropriate implementation, precise execution, regular evaluation and responsive adjustment. The proposed logic model framework serves as a roadmap for LTCFs, both current and future users of eMAR.

Optimizing Hospital Electronic Prescribing Systems: A Systematic Scoping Review

OBJECTIVE

Considerable international investment in hospital electronic prescribing (ePrescribing) systems has been made, but despite this, it is proving difficult for most organizations to realize safety, quality, and efficiency gains in prescribing. The objective of this work was to develop policy-relevant insights into the optimization of hospital ePrescribing systems to maximize the benefits and minimize the risks of these expensive digital health infrastructures.

METHODS

We undertook a systematic scoping review of the literature by searching MEDLINE, Embase, and CINAHL databases. We searched for primary studies reporting on ePrescribing optimization strategies and independently screened and abstracted data until saturation was achieved. Findings were theoretically and thematically synthesized taking a medicine life-cycle perspective, incorporating consultative phases with domain experts.

RESULTS

We identified 23,609 potentially eligible studies from which 1367 satisfied our inclusion criteria. Thematic synthesis was conducted on a data set of 76 studies, of which 48 were based in the United States. Key approaches to optimization included the following: stakeholder engagement, system or process redesign, technological innovations, and education and training packages. Single-component interventions (n = 26) described technological optimization strategies focusing on a single, specific step in the prescribing process. Multicomponent interventions (n = 50) used a combination of optimization strategies, typically targeting multiple steps in the medicines management process.

DISCUSSION

We identified numerous optimization strategies for enhancing the performance of ePrescribing systems. Key considerations for ePrescribing optimization include meaningful stakeholder engagement to reconceptualize the service delivery model and implementing technological innovations with supporting training packages to simultaneously impact on different facets of the medicines management process.

Reducing medication errors for adults in hospital settings

BACKGROUND

Medication errors are preventable events that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional or patient. Medication errors in hospitalised adults may cause harm, additional costs, and even death.

OBJECTIVES

To determine the effectiveness of interventions to reduce medication errors in adults in hospital settings.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers on 16 January 2020.  SELECTION CRITERIA: We included randomised controlled trials (RCTs) and interrupted time series (ITS) studies investigating interventions aimed at reducing medication errors in hospitalised adults, compared with usual care or other interventions. Outcome measures included adverse drug events (ADEs), potential ADEs, preventable ADEs, medication errors, mortality, morbidity, length of stay, quality of life and identified/solved discrepancies. We included any hospital setting, such as inpatient care units, outpatient care settings, and accident and emergency departments.

DATA COLLECTION AND ANALYSIS

We followed the standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care (EPOC) Group. Where necessary, we extracted and reanalysed ITS study data using piecewise linear regression, corrected for autocorrelation and seasonality, where possible.  MAIN RESULTS: We included 65 studies: 51 RCTs and 14 ITS studies, involving 110,875 participants. About half of trials gave rise to 'some concerns' for risk of bias during the randomisation process and one-third lacked blinding of outcome assessment. Most ITS studies presented low risk of bias. Most studies came from high-income countries or high-resource settings. Medication reconciliation -the process of comparing a patient's medication orders to the medications that the patient has been taking- was the most common type of intervention studied. Electronic prescribing systems, barcoding for correct administering of medications, organisational changes, feedback on medication errors, education of professionals and improved medication dispensing systems were other interventions studied. Medication reconciliation Low-certainty evidence suggests that medication reconciliation (MR) versus no-MR may reduce medication errors (odds ratio [OR] 0.55, 95% confidence interval (CI) 0.17 to 1.74; 3 studies; n=379). Compared to no-MR, MR probably reduces ADEs (OR 0.38, 95%CI 0.18 to 0.80; 3 studies, n=1336 ; moderate-certainty evidence), but has little to no effect on length of stay (mean difference (MD) -0.30 days, 95%CI -1.93 to 1.33 days; 3 studies, n=527) and quality of life (MD -1.51, 95%CI -10.04 to 7.02; 1 study, n=131).  Low-certainty evidence suggests that, compared to MR by other professionals, MR by pharmacists may reduce medication errors (OR 0.21, 95%CI 0.09 to 0.48; 8 studies, n=2648) and may increase ADEs (OR 1.34, 95%CI 0.73 to 2.44; 3 studies, n=2873). Compared to MR by other professionals, MR by pharmacists may have little to no effect on length of stay (MD -0.25, 95%CI -1.05 to 0.56; 6 studies, 3983). Moderate-certainty evidence shows that this intervention probably has little to no effect on mortality during hospitalisation (risk ratio (RR) 0.99, 95%CI 0.57 to 1.7; 2 studies, n=1000), and on readmissions at one month (RR 0.93, 95%CI 0.76 to 1.14; 2 studies, n=997); and low-certainty evidence suggests that the intervention may have little to no effect on quality of life (MD 0.00, 95%CI -14.09 to 14.09; 1 study, n=724).  Low-certainty evidence suggests that database-assisted MR conducted by pharmacists, versus unassisted MR conducted by pharmacists, may reduce potential ADEs (OR 0.26, 95%CI 0.10 to 0.64; 2 studies, n=3326), and may have no effect on length of stay (MD 1.00, 95%CI -0.17 to 2.17; 1 study, n=311).  Low-certainty evidence suggests that MR performed by trained pharmacist technicians, versus pharmacists, may have little to no difference on length of stay (MD -0.30, 95%CI -2.12 to 1.52; 1 study, n=183). However, the CI is compatible with important beneficial and detrimental effects. Low-certainty evidence suggests that MR before admission may increase the identification of discrepancies compared with MR after admission (MD 1.27, 95%CI 0.46 to 2.08; 1 study, n=307). However, the CI is compatible with important beneficial and detrimental effects. Moderate-certainty evidence shows that multimodal interventions probably increase discrepancy resolutions compared to usual care (RR 2.14, 95%CI 1.81 to 2.53; 1 study, n=487). Computerised physician order entry (CPOE)/clinical decision support systems (CDSS) Moderate-certainty evidence shows that CPOE/CDSS probably reduce medication errors compared to paper-based systems (OR 0.74, 95%CI 0.31 to 1.79; 2 studies, n=88).  Moderate-certainty evidence shows that, compared with standard CPOE/CDSS, improved CPOE/CDSS probably reduce medication errors (OR 0.85, 95%CI 0.74 to 0.97; 2 studies, n=630). Low-certainty evidence suggests that prioritised alerts provided by CPOE/CDSS may prevent ADEs compared to non-prioritised (inconsequential) alerts (MD 1.98, 95%CI 1.65 to 2.31; 1 study; participant numbers unavailable). Barcode identification of participants/medications Low-certainty evidence suggests that barcoding may reduce medication errors (OR 0.69, 95%CI 0.59 to 0.79; 2 studies, n=50,545). Reduced working hours Low-certainty evidence suggests that reduced working hours may reduce serious medication errors (RR 0.83, 95%CI 0.63 to 1.09; 1 study, n=634). However, the CI is compatible with important beneficial and detrimental effects. Feedback on prescribing errors Low-certainty evidence suggests that feedback on prescribing errors may reduce medication errors (OR 0.47, 95%CI 0.33 to 0.67; 4 studies, n=384). Dispensing system Low-certainty evidence suggests that dispensing systems in surgical wards may reduce medication errors (OR 0.61, 95%CI 0.47 to 0.79; 2 studies, n=1775).

AUTHORS' CONCLUSIONS

Low- to moderate-certainty evidence suggests that, compared to usual care, medication reconciliation, CPOE/CDSS, barcoding, feedback and dispensing systems in surgical wards may reduce medication errors and ADEs. However, the results are imprecise for some outcomes related to medication reconciliation and CPOE/CDSS. The evidence for other interventions is very uncertain. Powered and methodologically sound studies are needed to address the identified evidence gaps. Innovative, synergistic strategies -including those that involve patients- should also be evaluated.

Dose Verification Errors in Hospitals: Literature Review of the eMAR-based Systems Used by Nurses

BACKGROUND

The effectiveness of the dose verification features of the electronic medication administration record (eMAR) and complementary systems in the hospital setting is not well understood.

PURPOSE

The authors completed a narrative synthesis of literature findings on the effectiveness of eMAR-based systems in the hospital setting.

METHODS

A literature review was carried out across 5 bibliographic databases to evaluate the safety features of current eMAR-based systems in preventing dosing errors and design issues that impede their usability.

RESULTS

While eMAR-based systems are beneficial to reducing order and drug cross-checking errors, safe dose verification features are sporadically available for targeted tasks. Overall, the eMAR had little impact on preventing low to moderate dosing errors. Dosing errors may occur because of error-prone activities that result from system design and work process issues during medication administration.

Practice-enhancing publications about the medication-use process in 2019

PURPOSE

This article identifies, prioritizes, and summarizes published literature on the medication-use process (MUP) from calendar year 2019 that can impact health-system pharmacy daily practice. The MUP is the foundational system that provides the framework for safe medication utilization within the healthcare environment. The MUP is defined in this article as having the following components: prescribing/transcribing, dispensing, administration, and monitoring. Articles that evaluated one of the steps were gauged for their usefulness in promoting daily practice change.

SUMMARY

A PubMed search was conducted in January 2020 for calendar year 2019 using targeted Medical Subject Headings keywords; in addition, searches of the table of contents of selected pharmacy journals were conducted. A total of 4,317 articles were identified. A thorough review identified 66 potentially practice-enhancing articles: 17 for prescribing/transcribing, 17 for dispensing, 7 for administration, and 25 for monitoring. Ranking of the articles for importance by peers led to the selection of key articles from each category. The highest-ranked articles are briefly summarized, with a mention of why each article is important within health-system pharmacy. The other articles are listed for further review and evaluation.

CONCLUSION

It is important to routinely review the published literature and to incorporate significant findings into daily practice; this article assists in identifying and summarizing the most impactful recently published literature in this area. Health-system pharmacists have an active role in improving the MUP in their institution, and awareness of the significant published studies can assist in changing practice at the institutional level.

Effective Use of Mobile Electronic Medical Records by Medical Interns in Real Clinical Settings: Mixed Methods Study

Background

In South Korea, most graduated medical students undertake a 1-year internship before beginning residency and specialization. Interns usually work in a tertiary hospital and rotate between different, randomly assigned departments to be exposed to different medical specialties. Their jobs are mostly simple and repetitive but are still essential for the patient care process. However, owing to the lack of experience and overwhelming workload, interns at tertiary hospitals in South Korea are usually inefficient, often delaying the entire clinical process. Health care providers have widely adopted mobile electronic medical records (mEMRs) as they have been shown to improve workflow efficiency.

Objective

This study investigates the association between the frequency of mEMR usage and the clinical task completion interval time among interns in a tertiary hospital.

Methods

This mixed methods study was conducted at the Samsung Medical Center, Seoul, South Korea. Interns who worked at the Samsung Medical Center from March 2018 to February 2019 were included. The hospital electronic medical record (EMR) system known as DARWIN (Data Analysis and Research Window for Integrated kNowledge) was launched with PC and mobile. Both versions are actively used in hospitals by personnel in various positions. We collected the log data from the mEMR server and the intern clinical task time-series data from the EMR server. Interns can manage the process of identifying patients, assigning the clinical task, finishing the requested clinical intern tasks, etc, through the use of the mEMR system. We compared the clinical task completion interval among 4 groups of interns divided by the mEMR frequency quantile. Then, System Usability Score (SUS) questionnaires and semistructured interviews were conducted.

Results

The regular mEMR users were defined as those who logged in more than once a day on average and used the mEMR until the level after login. Among a total of 87 interns, 84 used the mEMR to verify the requested clinical tasks. The most frequently used item was “Intern task list.” Analysis of the 4 intern groups revealed an inverse relationship between the median time of the task completion interval and the frequency of mEMR use. Correlation analysis showed that the intern task completion time interval had a significant inverse relationship with the individual frequency of mEMR usage (coefficient=-0.27; 95% CI -0.46 to -0.04; P=.02). In the additional survey, the mean SUS value was 81.67, which supported the results of the data analysis.

Conclusions

Our findings suggest that frequent mEMR use is associated with improved work efficiency in hospital interns with good usability of the mEMR. Such finding supports the idea that the use of mEMR improves the effectiveness and workflow efficiency of interns working in hospitals and, more generally, in the context of health care.