Implementation of an Electronic Charting System

Editor's Notes

• #2: Reason for Change: Our hospital had 147 reported medication errors with two resulting in death last year. We want to eliminate future deaths and errors by implementing a technology based medication administration system that has been proven to reduce these errors. We are ready to implement this system after studying it for 6 months. We have interviewed our physicians, nurses, respiratory therapist and pharmacists about how the change would affect them. We have had representatives from all disciplines travel to hospitals where the eMAR is in use so they could experience it first hand. We have trialed the eMAR on a small scale for one month. The change to eMAR will affect all disciplines who prescribe, dispense and administer medication to patients. We are ready to implement eMAR and begin improving patient safety. We can no longer afford to ignore the technology that will improve patient care or stay with practices that don’t ensure patient’s safety. The following paragraph is a strong argument for the implementation of eMAR and discontinuing our current system.“The electronic medication administration record (eMAR) has gained a foothold in inpatient settings to support medication administration safety. With paper records prone to being lost, incomplete, or misread, the bedside nurse needs a fail-safe method to ensure that medications are administered correctly. Medication administration systems that integrate fully with computerized physician order entry (CPOE) and pharmacy systems should provide that fail-safe system, while improving efficiency. Even a standalone medication administration system is a vast improvement over paper medication administration records” ( Meadows, 2003).The eMAR is a computerized system that ensures the patient receives the correct medication, in the correct dose, at the correct time, and alerts staff when the proper parameters are not met. eMAR reduces relying on memory with a system that reminds clinical staff when medications need to be administered or the effectiveness of doses administered should be assessed.
• #3: Goals:Improve patient safety. We have studied the efficacy and safety record of similar systems such as the barcode medication administration (BCMA) system and found they have reduced medication errors. Studies at VA hospitals in the 1990s showed that BCMA use reduced medication errors by 86% (Meadows, 2003). This is a significant reduction that will benefit both patients and the hospital.2. Improve staff satisfaction. RNs decrease time administering medications, system is easy to use, it is a safety net to catch med errors alleviating some of the burden on nursing.Cost Savings: “ Patients who experienced adverse drug events (ADEs) were hospitalized an average of 8 to 12 days longer than patients who did not suffer ADEs, and their hospitalizations cost $16,000 to $24,000 more. Anywhere from 28 percent to 95 percent of ADEs can be prevented by reducing medication errors through computerized monitoring systems. Computerized medication order entry has the potential to prevent an estimated 84 percent of dose, frequency, and route errors. Hospitals can save as much as $500,000 annually in direct costs by using computerized systems” ( Agency for Healthcare Services, 2001).4. Accreditation: Program that increases patient safety are part of JCHACO’s safety initiative.  Implementation: Implementing an electronic system is a complex endeavor, which involves the training and integration of most hospital disciplines. The cost of initial implementation will be $1, 500,000. We will have eMAR capable computers on all floors. We will have scanning computers in all patient care areas, we will have a bar code medication dispenser in the pharmacy.We plan on implementing the system on the medical/surgical floor in one month and will go live hospital wide in three months.
• #4: Similar to other health implementations, barcoding and eMAR technologies require modifications to hospital policies on medication administration and patient identification. We will change our policy for eMAR use.POLICY: A. eMAR software will be used for administration of medications to all inpatients. Exceptions to this include all medications administered in the operating room or during an interventional procedure off the ward.  B. With the exception of emergent or immediate need situations, a valid provider order must be present in the prior to the administration of medication or intravenous fluids. An order for emergent medications will be entered as soon as possible. C. Only qualified staff, as defined per policy or scope of practice, will order, dispense or administer medication. D. All employees who are required to utilize eMAR will receive the training necessary to enable them to perform all required duties related to this system. Training will be adjusted to the needs of the individual employee. All staff that use eMAR to chart medication administration must pass a standard proficiency exam prior to use of the system.  E. The intent of eMAR software is to provide the nurse with an additional check and balance system that augments, but does not replace, clinical judgment. In order for the eMAR software to effectively provide the necessary check and balance system, the nurse must scan each patient's wristband and scan each medication as it is administered. The five rights must be practiced, circumventing the scanning process will increase the chances for user error.The policy will cover extenuating circumstances when patients can not wear wrist bands such as patients who are in isolation precautions, have infections or can not wear wrist bands for physical reasons such as allergy, swelling or safety issues. In these instances wrist bands can be taped to their doors or computer to be scanned. Extra caution will be used in these instances and the five rights must be confirmed by the RN.We have a contingency plan in the existence of system wide failure such as a power outage or software error There will be paper medication order sheets in all patient care areas. These will be used until the system is working again. All paper ordering will be discontinued when eMAR is working.Policy will be updated after one year use of eMAR.Copy of the new eMAR policy will be made available to all staff.
• #5: eMar stands for Electronic Medication Administration Record and it is a point-of-care process utilizing bar code reading technology to monitor the bedside administration of medications. Generally accepted inventory management processes include: Pharmacy to track medication inventory.Inventory management concepts to include item identification Patient Wristbands and medical records. Verification process and decision-making tool at 'point-of-care' at bedsideAt the patient bedside, if any of the scanned information does not match the doctor's orders, a warning message is provided to the clinician. (Bradyid, 2009).The eMAR system will include: Physicians who order medication Pharmacy who verify, prepare and dispense medication Nursing and Respiratory therapy who administer medicationThe following will be implemented with the eMAR system:Patients receive bar coded wrist bands at admit and must have one to before medication is administered.MDs can order medications from any computer in the hospital, all medications must be ordered electronically. Pharmacy will have the software to process and verify dosing medication, Pharmacy will notify physicians when medication is ordered incorrectly.The pharmacy will deliver bar coded medications to patient care areas. All medications including orals, IVs, creams, ointments and suppositories will be bar coded.Patient care areas will have computers with scanners to be used by nursing staff. All nurses will use scanners to scan patient wrist bands before administering any medication. The nurse will verify that the correct patient has been scanned then verify the patient’s medication list in the computer. All medication will be scanned and if alerts appear the nurse will act on them before administering the medication.The nurse will inform the patient about the importance of scanning the patient’s wristband, if a patient is incapacitated this can be deferred.A username and password will be required by all who use the eMAR. We plan on implementing the eMAR system on the medical/surgical floor starting at the beginning of next month and will introduce the system to the rest of patient care areas at the end of the month. We will go live hospital wide in three months. Managers in all departments including nursing, respiratory, pharmacy and MDs will have an in-service introducing the new system and explain the reasons for the change. We have ordered scanning computers and our IT teams are installing software in all hospital computers and in the pharmacy. We have brought in eMAR representatives and technicians to help us with our change. We will train staff in four hour sessions. We will have super users on all floors. We will have on line training and support 24/7. We will not use penalties for those who are not ready to use the system but will provide further training. Our goals for introducing eMAR to the staff will be:Ensure ease of use.Minimize training requirements.Use existing technology.Limit variations and exceptions.Require use.
• #6: As part of the eMAR implementation we will discontinue all previous medication administration practices. We will educate all disciplines to the new system with in-services, on hand technicians and computer software courses that are accessible by all 24/7.Physicians are no longer allowed to write medication orders by hand or in patient chartsPhysicians can not phone orders into the pharmacyVerbal medication orders must be entered by the receiver into the computerPharmacy can not deliver medication that is not bar coded to patient care areas.We must discontinue old practices of medication administration once eMAR is in place. Compliance with the new system will ensure optimal results. Staff education and training are paramount for us to be successful. We have found documentation that having two systems can be detrimental to patients and nurses.“ Dual medication systems (i.e., the use of paper MARs in tandem with electronic BCMA documentation) increase the probability of medication error and reduce nursing productivity, as indicated previously in a study by Patterson et al., that examined the human factors issues related to BCMA implementation in a VHA institution. Baseline data collected by our BCMA Collaborative Team in September 2003 indicated that 60 percent of one-time medications and 42 percent of PRN medications for CABG patients were documented in the BCMA system, so the risk of medication error was great. The ICU eliminated paper MARs on November 18, 2003, in favor of the paperless system. Since that time, the documented percentage of these same medications in the BCMA system has risen to more than 95 percent, and several nurses have expressed the opinion that their overall workload has decreased as well” (Meadows,2003).
• #7: Identifying or recruiting a change agent should be the first step in any organization interested in implementing an EMAR system. We suggest a change agent that has previous experience with the implementation of an eMAR system. Inadequate financial or physical resources: Since most hospitals are not profit turning companies, it can be difficult to attain the necessary funding to implement the EMAR change. Costs can run from $4 million to upwards of $35 million on implementation alone and this does not include the costs of maintaining the system (Granlien, Hertzum, & Gudmundsen, 2008). We need to analyze the full costs that implementation and maintenance will entail. This includes the costs of bringing the hospital technology up to par. Lack of support from other disciplines: Lack of support from all disciplines like MDs: Physicians are used to ordering meds through the old system and may not adopt this system.An organization might have poor leaders or those that are reluctant or resistant to change at the helm. It is important to identify those leaders, educate, convince and get them committed to the change process. Lack of technology: Before an EMAR system can be implemented, the organization should have a detailed understanding of the existing technology and hardware in the facility. The cost of purchasing and implementing a software system is only 50% of the total cost of the EMAR system (Wiemar, 2009). The actual installation of the entire system; which includes installing or updating computers, adding a barcode medication dispenser in the pharmacy, making sure that all the equipment is ‘talking to each other’, making sure everything is working and having technical support available.Failure: Since people are more resistant to change when there has been a previous failure (Spector, 2010), getting the organization to move away from the defeatist mentality and back into an optimistic , fluid realm of possibilities can be a huge hurdle that many organizations cannot overcome.Time: Implementing an EMAR system can take anywhere from 6 months to several years. Employees can quickly become disinterested or skeptical that the ‘change is never going to come’. To avoid this, it’s essential to have the necessary building blocks already in place so that the employees can see that the change is moving ahead at a measurable pace. We have to set deadlines and goals, communicate them to the whole organization; and give a good overview of what has been accomplished and what still needs to be done (Spector).
• #8: Feelings of uncertainty based on the unknown: Employees require an sense of stability in the workplace (Spector, 2010). When change does occur, feelings of insecurity and fear of loss of power, skills or loss of income may increase the resistance. To counteract this, leaders should communicate the stages of the EMAR process, and what the employee’s new requirements will be in a timely manner. Reduction in personal need fulfillment: Some nurses or pharmacists might feel like they are being ‘replaced’ and made redundant (Carr, 2004), or that their autonomy is being taken away. Others might feel like they are going to be unable to perform as well in the new situation since they are not comfortable with the technology. Thus, they feel a reduction in personal and professional fulfillment. To overcome this barrier, we must stress that the EMAR system does not replace jobs; but is important to reduce medication errors, improve patient safety and enhance healthcare delivery. Real or perceived stress: If individuals project that implementing EMAR will be stressful, additional behavioral and emotional blocks need to be overcome. We should advocate stress how easy the system is to use, and how effectively it can be utilized. Highlighting the superb advantages of the EMAR system can help eliminate some of that stress. Failure to accept need for change: Many nurses might be mired in tradition with set ways, and feel like there is no need to convert to an EMAR. To sway this mindset, it is important to stress how EMAR serves as a fail safe in avoiding medication errors. Since the program covers the 5R’s and will notify the nurse of any discrepancy, it protects the nurse and facility from potential hazardous mistakes. Fear of technology on the complexity of the system. Some nurses might not have technical skills and will be intimidated by the computer system, so they might resist it. Some nurses might feel that if the scanner is broken, not scanning, or if they forget how to work the system, it might “make them look stupid in front of the patient” (Granlien, et al, 2008, p. 419). The change agents must impart the idea that if technology breaks down, it is not a reflection on the nurse, but a reflection of the system. Another complaint of nurses is that in emergent situations, the EMAR system can be tedious. To overcome this, it is essential to have emergent protocols in place to circumvent the system as long as appropriate documentation is in place. Takes too much time: Some nurses might feel that scanning will take too much time. To counteract this it is important to stress the benefits of the system in reducing errors and that once one is comfortable with it, it will actually cut down on the time taken to dispense medications.
• #9: There is a lot of repetitive reasoning, but it must be stressed to the staff that the goal of bar coding and eMARs is to enhance patient safety. Here are some facts about medication errors in the United States. There are 7,000 deaths per year in U.S. hospitals due to medication errors (Patient Safety & Quality Healthcare [PSQH], 2005). The VA Medical Center in Topeka, Kansas reduced it’s medication errors by 86.2% after the implementation of the eMAR system. Other hospitals have shown a decrease in errors by up to 80% (PSQH).This new change will ensure that the 5 Rights of Medication Administration are followed. They are listed above. We cannot forget that near misses and medication errors can be ultimately prevented with bar scanning and eMARs. The system is already set up to trigger alerts and warnings in regards to sound-alike or look-alike drugs, a National Patient Safety Goal that JCHACO is very particular about. This will ensure our hospital’s compliance with the latest medication standards and protect our patients from potentially hazardous mistakes.
• #10: Having a more technologically advanced hospital will generate positive public relations in the community. The eMAR system will ensure that the staff has legible orders, and they will not have to scrutinize and guess at physician’s hand written orders since everything will be computerized. The eMAR System ensures easy bedside documentation in real time. This cuts down on ‘forgetting’ what time a medication was administered. In addition, the new system gives access to immediate data in the clinical setting, accessible from all computers hooked to the system.It improves nursing staff job satisfactionThe eMAR system ensures that nurses will have a reduction in the incidence of medication errors.Patient satisfaction will be increased, due to the fact that patients will realize that prior to giving medication there is an extra effort to confirm they are getting the right medication, the right dose, right time, the right route and of course the right patient.
• #11: This slide lists a few more factors that may influence the bar coding system.Repetitive motion has been shown to lead to carpal tunnel. By using the eMAR system, there is less gripping of pens in the workplace, and nurses will have less manual data entry activities with bar scanning.The eMAR system provides an accurate tracking system, inventory management, real time charting and patient billingThe eMAR system allows pharmacists to focus on clinical duties instead of dispensing tasks. This allows pharmacists to be more easily accessible and available to staff, physicians and patients for education and consulting purposes.The final point is that one of the National Patient Safety Goals for 2009 as required by JCACHO is having 2 patient identifiers for medication administration. By using the new system, this supports our organizations’ compliance with the National Patient Safety Goals and also promotes our accreditation process since we have the system already in place.
• #12: To achieve outstanding results in the areas of productivity improvement, employee commitment, smoother running processes, resource integration and your management development; Learning Team A offers tips.Douglas McGregor (the author of Theory ‘Y’) believed that people want to learn and that work is their natural activity to the extent that they develop self-discipline and self-development. Employees see their reward not so much in cash payments as in the freedom to do difficult and challenging work by themselves. The job of the manager is to ‘dovetail’ the human wish for self-development into the organization’s need for maximum productive efficiency. Therefore, the basic objectives of both are met and with sincerity and imagination, the enormous potential can be tapped. According to Frederick Herzberg, the author of the Hygiene/Motivation Theory, people work first and foremost in their own self-enlightened interest. Hygiene factors are supervision, interpersonal relations, working conditions and salary. These are the animal needs of people. The human needs (motivators) are recognition, work, responsibility and advancement. Unsatisfactory hygiene factors can act as de-motivators, but if satisfactory, their motivational effect is limited. To meet the human needs more; consider offering shorter work weeks, increased wages, fringe benefits, sensitivity/human relations training and effective communication. Victor Vroom’s Expectancy Theory (VIE Theory) suggests that for any given situation, the level of a person’s motivation with respect to performance is dependent upon his or her desire for an outcome and that the individual’s job performance is perceived to be related to obtaining other desired outcomes; and the perceived probability that his or her effort will lead to the required performance. This theory can be expressed as M=V x I x E .Motivation equals the valence times the instrumentality times the expectancy. This theory is very useful because it helps to understand a worker’s behavior. If employees lack motivation, it may be caused by their indifference toward, or desire to avoid, the existing outcomes. The important question to ask is, “What rewards (outcomes) do your employees value?” Understanding individuals and what motivates them can be a challenge because employees are diverse not only in culture, race and gender, but varying levels of education. It is hoped that these three theories of motivation will assist you in predicting employees’ behavior so that one or more of these theories can be implemented to influence the behavior that is desired. Then and only then, will the organization achieve success through increased job satisfaction.
• #13: Any questions?