Introduction of Electronic Prescribing

 

A brief informal commentary

Gentamicin incidents have increased

Our previous separate gentamicin chart fulfilled all of the previous NPSA alert requirements. With introduction of EPIC many of the safeguards were lost resulting in doses being given too close together or large delays between doses as EPIC could not schedule the times correctly. Also difficult to track back and correlate level results with when doses had been administered. As a result, quite a lot of work was done to improve the situation. This has allowed the double checking prompts, that nurses should use prior to gentamicin administration, to be incorporated in EPIC as part of the administration process and improvements in how EPIC schedules 24 and 36 hourly dosing.

Prescription Complexity

Medical staff sometimes struggle to find the exact prescription order that is required, so they find something close and then add ‘admin instructions’ to make the order work – this could potentially result in the wrong drug or dose being administered if admin instructions are not read.

Warning fatigue

There are so many pop up warnings that lots of people just pick ‘benefit overweighs risk’ option to close the warnings screen without reading the warnings. There have been some duplicate orders that have resulted in duplicate administration – in these cases warnings have been ignored by prescribers and nursing staff administering. I would suggest that when implementing a new e-prescribing system that a low number of important warnings are initially used and then further levels of warnings could be added if needed.

Prescription End Dates

If an end date for a prescription is reached then the prescription will stop in EPIC with no warning e.g. antibiotics stopping when they need to continue. In theory if a proper review of prescribed medication is undertaken each day on the ward round, then orders that are close to expiring can be reviewed.

Rounding Errors

Sometimes when a tablet needs to be crushed and dispersed in water to administer a dose, if the EPIC build is not correct the dose will round up or down with a massive difference to the intended dose – this can be resolved by the EPIC team once they know what level of rounding is required, but the delay in resolving this may increase the risk of an incorrect dose being administered.

Administration Records

If there is a significant delay in administering a dose then subsequent drug timings on the MAR will not change to reflect this – requires nursing staff to highlight that timings need to be rescheduled. Timings are also an issue with some types of frequency options in EPIC e.g. using ’24 scheduled’ frequency means that if first dose is given in the evening, then EPIC automatically schedules it’s normal daily frequency in the morning, meaning that if left unchanged the first 2 doses will be given too close together.

Impact on Pharmacist Time & Resource

Pharmacist time has increased in reviewing prescriptions, due to incorrect orders being selected by the prescriber and requiring change to a more appropriate prescription order. EPIC requires the prescriber to know much more than the drug, dose, route and frequency – they now need to know which strength of preparations we keep in pharmacy. In particular on a paediatric ward where they have trialed bar code administration, this relies on the prescriber choosing the exact correct order and also having a pharmacist available to verify the order before the bar-coding can be used.

• Pharmacist time has also increased to support prescribers in selecting the correct order or how to use some aspects of EPIC.

Completed/Discontinued Therapies

Drugs that are no longer required e.g. infusions will remain on the MAR until the prescriber discontinues these – requires a daily review of the MAR.

Advance Planning

Organisation of drugs prior to a day case visit is still a problem and requires a specific way of ordering and then pharmacy being contacted with the order history number and details of which clinical area the drug will be administered. If ordered incorrectly either pharmacy can’t view the order or the nurse only sees a read only version on the MAR.

Reviewing Medications

Looking back through the MAR or MAR reports to see when previous doses were administered can sometimes be difficult.

Workflow Issues

Seems possible to prescribe drugs without weight leaving the dose as mg/kg option, instead of a calculated dose.

Duplicate Prescriptions

Still issues with patients peri-operatively where EPIC classes ward and theatre as a separate encounter and so doses given on ward can potentially be repeated in theatre and vice versa, without any warning.

Lessons Learned

• Paediatric units within larger adult hospitals should employ a paediatric pharmacist as part of the build team, with back-fill for their day to day job.
• The system should be trialed before go-live to try and identify as many problems as possible.
  • Worth thinking about some prescribing scenarios in different clinical areas to test the system.
  • We started to identify problems during the ‘cut over’ process when inputting drugs on EPIC from the old drug charts.

Observed Benefits

• No concerns about legibility
• Order sets with pre-defined prescriptions for different areas have been really good.
• Drug infusions for PICU and NICU particularly were really well built and allow easy titration of drugs using the MAR and allow double/quadruple strengths of the infusions to be easily prescribed (I think this is very difficult to achieve with some other e-prescribing systems).
• Admin instruction notes are good for adding specific information on drug administration.
• Medicines reconciliation process works well when used properly.
• Ability to review prescription or for prescriber to amend a prescription for any location with EPIC access is great and saves lots of time and potential error occurring.
• Audit of prescription and administration processes is useful for feedback if an error occurs.
• Warnings can be useful when read by users.