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Mind the Gap: The last few metres to the patient can be the deadliest...

Medication errors which occur at the point of administration are the hardest to detect.

It is generally accepted that even with aggressively managed hospital formularies, matching Automated Dispensing Cabinet (ADC) medication libraries, extensive and ongoing training, and compliance monitoring that medication errors will still take place at the bedside. This is simply because these systems, whilst they do much to protect the patient from error during the prescription and dispensing parts of the medication chain, can do very little to prevent errors at the point of administration, which can extend to Wrong Patient, Wrong Medication, Wrong Dose, Wrong Documentation, and Wrong Time. Indeed, the Joint Commission International (JCI) consistently retains ‘Identifying Patients Correctly’ before any therapeutic intervention as its ‘International Patient Safety Goal Number One’ in every renewal of its standards.

Furthermore, among all of the parts of the medication chain – from prescription through to administration – medication errors which occur at the point of administration are the hardest to detect. With only a 2 per cent chance of detection of error, in terms of Failure Mode Effect Analysis (FMEA) the administration process consistently scores as a high-risk activity by virtue of the difficulty of detection, with a score of 10 commonly being applied by organisations utilising FMEA (FMEA Detectability Scale: 0 Minimum Harm Risk - 10 Maximum Harm Risk).

This is the dangerous ‘gap’ that Connected Mobile Medication Carts can close, as they bring the medications for the patient right to the bedside in secure compartments, allow for documentation of administration at the point of care, and through integration, with the patient’s Electronic Medical Record (EMR) they can achieve closed-loop Bar Code Medication Administration (BCMA).

BCMA via Integrated Mobile Medication Carts is capable of mitigating the following types of administration errors: Wrong Patient, Wrong Medication, Wrong Dose, and Wrong Time. They also ensure correct recording of medication administration. Auto-documentation via BCMA is made directly into the patient’s EMR and is certainly superior to manual completion of the medication record as manual documentation may be delayed or inaccurate as clinicians attend to emergent situations or distractions. Once clinicians return to their documentation after a patient care event such as medication administration, they often transcribe from memory, and commonly introduce human error into the process.

Connected Mobile Medication Carts complete the closed-loop and bridge the gap of the last few meters from the ADC to the patient through a simple workflow underpinned by close integration from the Connected Mobile Medication Cart into the ADC-Pharmacy inventory system to avoid drug unavailability and to the hospital EMR and Computerized Provider Ordering System (CPOE) to ensure that the Right Order is dispensed to the nursing unit and correctly administered at the bedside.

For the user, the workflow is straightforward:

  • Each drawer of the Connected Mobile Medication Carts is electronically labelled and auto-assigned to a specific patient based on the EMR synchronising its Admission, Discharge and Transfer data with the cart. The individual, patient-specific drawers can be loaded with medication in the pharmacy, or from the nursing unit’s ADC.
  • Specific patient orders can be routed to individual carts, so in large nursing units, primary nursing and named-nurse patient care can be maintained.
  • When a medication is administered, the nurse scans the patient’s wristband and the appropriate compartment, containing only that patient’s medications, unlocks automatically.
  • Higher capacity carts are capable of managing a 32 bedded nursing unit, but it is advisable to restrict the ‘loading’ of any cart to a maximum of 16 patients simply to allow for multiple medications and larger items to be loaded (pre-mixed subcutaneous injections and even intravenous medications can be loaded into the cart) and to ensure timely medication delivery to every patient on the nurses’ medication rounds.
  • Bespoke sizes of compartments and drawers, dividers and shelves within the Connected Mobile Medication Cart should allow for complex treatments that require multiple medications or mixing of components for non-oral orders.
  • Each cassette must be removable and interchangeable from cart to cart, to allow for patient transfer from one area to another, and to match the Admission, Discharge and Transfer patient data. (Figure 1) There must be multiple drawer configurations, allowing drawers to be switched from cart to cart without the need for tools, and employing RFID embedded technology to avoid patient assigned cassettes from being mixed-up.
  • Overrides can be made in the event of a patient emergency or facility power failure.

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Figure 1

Connected Mobile Medication Carts carry a lot of technology and a lot of weight! Ideally then, they should be powered to assist the clinician in moving between patients, and such is the nature of nursing that one-hand operation is desirable for ‘care on the go’. As the Connected Mobile Medication Cart will be used by multiple clinicians in any nursing unit it is also desirable that it can adjust automatically to each user’s height.

For senior nurses and for pharmacists, Connected Mobile Medication Carts have several powerful advantages over the traditional ‘administer and sign’ medication administration as every user event is recorded including

  • Clinician log-ins.
  • Patient barcode scans.
  • Manual overrides for access and drawer opening/closing.
  • Admission, Discharge and Transfer notifications are sent directly to the Connected Mobile Medication Cart, allowing medication needs and orders to keep up with rapid patient movement through the organisation.
  • Active Directory integration must be available on the Connected Mobile Medication Cart in order to manage access to the cart based on each clinician’s privileges within the organisation and with an organisation-wide Single Sign On. In times of high staff turnover and staff needing multiple accesses to networks, services and medical devices, this is vital.

All of this brings a high level of accountability and visibility into the medication administration process.

In a recently held Medication Safety Advisory Board Meeting in Switzerland, the chief concerns of the assembled pharmacy, medical and nursing specialists were:

  • End-to-end medication safety.
  • Improved clinician and IT efficiency.
  • Enterprise medication inventory optimisation.

The Advisory Board saw the overarching aim of the medication chain to be the administration of the correct medicines at the correct dose, at the correct time, in a patient-led and safe manner. The advisory board also made clear that any bedside verification system implemented should be extremely prescriptive and clear and follow as a logical and transparent chain from the CPOE through dispensing systems and ADCs directly to the bedside.

In practical terms, the Advisory Board stated that this requires a move from documentation at the nursing station or ‘desk’ to the documentation at the bedside and that nurses should both document the patient’s vital signs pre-medication if required, and then move directly to scanning prescribed medications before administration directly at the bedside. In terms of Connected Mobile Medication Carts, this requires the ability to include automated extensions of the ADC to assign drugs to a specific drawer on the Connected Mobile Medication Cart, in order to improve transferability, to allow for control of narcotics, and to allow for accurate and complete billing.

The deployment of Connected Mobile Medication Carts speaks directly to a central issue in modern healthcare, that of Return on Investment (ROI) as systems employing interoperability between the patient’s Electronic Medical Record and Connected Mobile Medication Carts through closed-loop Bar Code Medication Administration require investment. But with medication errors costing an average of US$9,000 per event and causing an average Length-of-Stay extension of 4.8 days, we cannot afford to keep ignoring all those ‘Mind The Gap’ warnings.

References available on request.


OH mag issue 3_small.jpgThis article appears in the March/April edition of Omnia Health Magazine. Other topics include AI in healthcare, patient safety, mobile healthcare and further updates around on COVID-19 from the healthcare industry.

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