Evidenced Based Nursing: Electronic Medical Charting and Patient Safety

1. Evidenced Based Nursing: Electronic Medical Charting and Patient Safety Presented By Nicole Chambers, Sharon Herring, Sheila Lucas, and Shelley Meyerholtz

2. Introduction • In the 1999 publication of To Err is Human, one of the Institute of Medicine (IOM) recommendations included the utilization of electronic medical records as a way to standardize patient care, reduce waste, and improve patient safety • This has been a huge undertaking for the healthcare industry leaving many of us to wonder if we are seeing benefits in this change

3. Problem Statement • In the inpatient acute care setting, what does the literature reveal about differences in quality of nursing care between paper based charting and computer based charting? Quality indicators to be examined in this literature review include increasing patient safety by decreasing medication administration error rates

4. Hypothesis • There is a decrease of medication errors with the use of electronic charting

5. Literature Review – Crane, J. and Crane, F.G. (2006). Preventing medication errors in hospitals through a system approach and technological innovation. • Found 44,000- 98,000 people die in the US each year because of medical errors. Despite these numbers research indicates that most of medical errors are preventable. “A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in control of the healthcare provider or patient” (Crane and Crane, 2006. P. 3) • Found the problem of health care systems is that patients’ medical records are found in different departments and they may even have more than one medical record • Solutions offered: • Use of Failure mode effects analysis (FMEA) - a system used to “…recognize and evaluate the potential failures…,” “…identify actions that could eliminate or reduce the chance of potential failures occurring…,” and “…document the entire process” (Crane and Crane, 2006. P. 4) • Use of electronic medical record, computerized physician order entry and bar coding technology as well as robotic dispensing technology • Barriers identified: • Cost • Patient Privacy • Conclusion was that utilizing technology with reduces medical error and improve patient safety

6. Literature Review – Schnipper, J. L. et al. (2009). Effect of an Electronic Medication Reconciliation Application and Process Redesign on Potential Adverse Drug Events: A Cluster-Randomized Trial. • Study was aimed at improving medication reconciliation from admission to discharge. • Utilized a “…computerized medication reconciliation tool...” (Schnipper et al., 2009, p 771) as well as redesigning the processes of pharmacist, physicians and nurses as interventions for the study conducted using 322 patients between 2 academic hospitals. 160 patients were among the control group and 162 patients were the intervention group. • Results: 230 possible potential adverse drug events among the control group. 170 possible adverse drug events were found among the intervention group. • The redesigns encourage interdisciplinary communication and double checks. • Barriers: • Patients and caregivers not always accurate with medication history • Problems with software of the medication reconciliation and staff adherence to process • Concluded that there was a decrease in potential and actual adverse medication events with the interventions (Schnipper et al., 2009).

7. Literature Review – FitzHenry, F,. Peterson, J., Arrieta, M., Waitman, L., Schildcrout, J., Miller, R. (2007). Medication administration discrepancies persist despite electronic ordering. • Study discussed computerized provider order entry (CPOE) related to medication administration discrepancies • Aim was to look at lag time between order time and administration time and to identify administration errors that existed despite computerized ordering • Completed at a 658 base hospital that utilized a CPOE but did not have electronic medication administrating charting. The sample was chosen based on 6 regularly prescribed medication classes. These criteria allowed for over 10,000 admissions to qualify for the study (FitzHenry et al., 2007). • Results – Showed delays in medication administration still occurred in all environments where computer based ordering had eliminated delays related to transcribing and transporting orders to the pharmacy. • Delays were attributed to pharmacy dispensing to hospital location, administration time once meds were on the floor, and inefficient delivery of new orders to the pharmacy. • Barriers: • 4 year study • No direct observation of errors • Study only included six medication classes • Electronic medication administration records (EMAR’s) not utilized in facility studied • Conclusion was that while computerized provider order entry systems are helpful in decreasing medicaiton errors- there are other important problems related to scheduling and administration that need addressing as well

8. Literature Review-Abbass, I., Helton, J., Mhatre, S., & Sansgiry, S. (2012). Impact of electronic health records on nurses' productivity. • Looked at how electronic health records (EHR) affects nurse’s productivity • Hypothesized that hospitals who utilized the EHR would require less nurses than hospitals with a lower level of EHR usage (Abbass et al., 2012). • Retrospective cross sectional design- studying data collected from 2007 and 2008 from the American Hospital Association (AHA) survey and Centers for Medicare and Medicaid Services (CMS)- looking at 3368 hospitals. • Results indicated that “hospitals with high EHR penetration did not demonstrate more productivity as it was anticipated that higher EHR would lead to reduced number of nurses. Nevertheless, using EHR in hospitals with higher CMI (case mix index) could provide more efficiency compared with their counterparts with lower CMI” (Abbass et al., 2012. p240).

9. Analysis of Evidence • Analysis of the evidence supports that EMAR’s decrease medication errors • Medication errors are facility wide problems requiring facility wide responses • Additional staff may be needed for facilitate the use of new applications • Updating the applications is ongoing and crucial to assist ing preventing medicaiton errors • System wide support decision backed by medical information joined with the rising technologies is the best solution for preventing medication errors • Data suggests that the IOM and JACHO regulations for change to nationwide electronic charting is a necessary change • EMR’s are time consuming and require dedication by staff; however with the implementation of these applications it has been proven that medication errors have decreased allowing safer patient outcomes.

10. Barriers and Application • Timing- related to knowing if the medication errors that occurred all being captured correctly • Direct observation during time of study would assist in reduction/elimination of this barrier • Facilities used in research studies – Possibly difference in reporting when comparing a teaching facility to a non teaching facility • Technology savvy-ness of facilities and staff members • As well as the user-friendliness of the electronic medical record used in each facility • “Hospitals who have low electronic health records (EHR) implementation may be more reluctant to report their status of nursing productivity” (Abbass, Helton, Mhatre, & Sansgiry, 2012)

11. Application cont. • Future studies based on timing of the medication administration • Focusing on medication scheduling and administration consistency • Consistency with environment being studied • Teaching hospital versus non teaching hospital

12. Suggestions for Future Research • “Future studies should be conducted to estimate the long term financial impact of EHR on productivity with various outputs” (Abbass, Helton, Mhatre, & Sansgiry, 2012). • Group consensus to suggest that more recent or current studies be done now that more facilities are complying with these regulations • We suggest that a study be done on a facility/facilities that have not yet switched to electronic charting and follow them through the change over • Suggest this be done prior to the mandate which is for conversion by 2014

13. Conclusion • Analysis of the reviewed literature conclude that despite the many barriers that exist with electronic medical charting – there is a significant decrease in medication administration error related to the use of EMAR’s • This supports the hypothesis that Electronic medical charting helps to decrease medication administration errors.

14. References • Abbass, I., Helton, J., Mhatre, S., & Sansgiry, S. (2012). Impact of electronic health records on nurses' productivity. CIN: Computers, Informatics, Nursing, 30(5), 237-241 • Crane, J. and Crane, F.G. (2006). Preventing medication errors in hospitals through a system approach and technological innovation. Hospital Topics.84(4). pp 3-8. Retrieved from http://www.tandfonline.com/doi/abs/10.3200/HTPS.84.4.3-8 • FitzHenry, F,. Peterson, J., Arrieta, M., Waitman, L., Schildcrout, J., Miller, R. (2007). Medication administration discrepancies persist despite electronic ordering. Journal of the American Medical Informatics Association. 14 (6)756-764. Retrieved from http://0-www.ncbi.nlm.nih.gov.libcat.ferris.edu/pubmed?term=medication%20adminstraion%20discrepancies%20persist%20despite%20electronic%20ordering • Institute of Medicine. (1999). To Err is Human: Building a Safer Health System. Retrieved from http://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf • Petrov, T. (2012). Physical Therapy Practices Turn to EMR to Offer better Care to Patients. Get Holistic health. http://www.getholistichealth.com/7147/physical-therapy-practices-turn-to-emr-to-offer-better-care-to-patients/ • Schnipper, J. L., Hamann, C., Ndumele, C. D., Liang, C., Carty, M., Karson, A., Bhan, I., Coley, C., Poon, E., Turchin, A., Labonville, S., Diedrichsen, E., Lipsitz, S., Broverman, C., McCarthy, P., Gandhi, T. (2009). Effect of an Electronic Medication Reconciliation Application and Process Redesign on Potential Adverse Drug Events: A Cluster-Randomized Trial. Arch Intern Med. 2009;169(8):771-780. doi:10.1001/archinternmed.2009.51