Hospital electronic prescribing system implementation impact on discharge information communication and prescribing errors: a before and after study

European Journal of Clinical Pharmacology, Jun 2017

Purpose The study aimed to test the hypothesis that hospital electronic prescribing and medicine administration system (HEPMA) implementation impacted patient discharge letter quality, nature and frequency of prescribing errors. Method A quasi experimental before and after retrospective case note review was conducted in one United Kingdom district general hospital. The total sample size was 318 (random samples of 159 before and after implementation), calculated to achieve a 10% error reduction with a power of 80% and p < 0.05. Adult patients discharged after ≥24-h inpatient stay were assessed for discharge information documentation quality using a modified validated discharge document template. Prescribing errors were classified as medicine omissions, commissions, incorrect dose/frequency/duration, drug interactions, therapeutic duplications or missing/inaccurate allergy information. Post-implementation assessments were undertaken 4 months following HEPMA implementation. Error severity was determined by a multidisciplinary panel consensus using the Medications at Transitions and Clinical Handoffs (MATCH) study validated scoring system. Results There were no statistically significant differences in patient demographics between the pre- and post-implementation groups. Discharge information documentation quality improved; allergy documentation increased from 11 to 159/159 (p < 0.0001). The number of patients with prescribing errors reduced significantly from 158 to 37/159 (p < 0.001). Prescribing error category incidence identified in pre-implementation patients was reduced (e.g. omission incidence from 66 to 18/159 (p < 0.001)), although a new error type (sociotechnical [errors caused by the system]) was identified post-implementation (n = 8 patients). Post-implementation prescribing errors severity rating identified 8/37 as likely to cause potential patient harm. Conclusion HEPMA implementation was associated with improved discharge documentation quality, statistically significant prescribing error reduction and prescribing error type alteration. There remains a need to be alert for potential prescribing errors.

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Hospital electronic prescribing system implementation impact on discharge information communication and prescribing errors: a before and after study

Hospital electronic prescribing system implementation impact on discharge information communication and prescribing errors: a before and after study Pamela Ruth Mills 0 1 Anita Elaine Weidmann 0 1 Derek Stewart 0 1 0 School of Pharmacy and Life Sciences, Robert Gordon University , Aberdeen AB10 7GJ, Scotland , UK 1 University Hospital Crosshouse, Pharmacy Department , Kilmarnock, Ayrshire KA2 OBE, Scotland , UK 2 Pamela Ruth Mills Purpose The study aimed to test the hypothesis that hospital electronic prescribing and medicine administration system (HEPMA) implementation impacted patient discharge letter quality, nature and frequency of prescribing errors. Method A quasi experimental before and after retrospective case note review was conducted in one United Kingdom district general hospital. The total sample size was 318 (random samples of 159 before and after implementation), calculated to achieve a 10% error reduction with a power of 80% and p < 0.05. Adult patients discharged after ≥24-h inpatient stay were assessed for discharge information documentation quality using a modified validated discharge document template. Prescribing errors were classified as medicine omissions, commissions, incorrect dose/frequency/duration, drug interactions, therapeutic duplications or missing/inaccurate allergy information. Post-implementation assessments were undertaken 4 months following HEPMA implementation. Error severity was determined by a multidisciplinary panel consensus using the Medications at Transitions and Clinical Handoffs (MATCH) study validated scoring system. Results There were no statistically significant differences in p a t i e n t d e m o g r a p h i c s b e t w e e n t h e p r e - a n d p o s t - implementation groups. Discharge information documentation quality improved; allergy documentation increased from 11 to 159/159 (p < 0.0001). The number of patients with prescribing errors reduced significantly from 158 to 37/159 (p < 0.001). Prescribing error category incidence identified in pre-implementation patients was reduced (e.g. omission incidence from 66 to 18/159 (p < 0.001)), although a new error type (sociotechnical [errors caused by the system]) was identified post-implementation (n = 8 patients). Postimplementation prescribing errors severity rating identified 8/37 as likely to cause potential patient harm. Conclusion HEPMA implementation was associated with improved discharge documentation quality, statistically significant prescribing error reduction and prescribing error type alteration. There remains a need to be alert for potential prescribing errors. HEPMA; Prescribing error; Sociotechnical error Introduction Hospital electronic prescribing and medicines administration (HEPMA) systems were defined by the Department for Health in England in 2007 as ‘the utilisation of electronic systems to facilitate and enhance the communication of a prescription or medicine order, aiding the choice, administration and supply of a medicine through knowledge and decision support and providing a robust audit trail for the entire medicines use process’ [ 1 ]. UK government strategy recommends HEPMA system implementation, with National Health Service (NHS) England and NHS Scotland policies committed to HEPMA as a future ehealth model in all secondary healthcare settings [ 2, 3 ]. Reported advantages of electronic prescribing systems include increased patient safety by prescribing error reduction. The UK Health Foundation stated that implementation of an electronic prescribing system incorporating decision support functionality could realise a 50% prescribing error reduction [ 4 ]. These systems also have the capacity to create prescriptions at the point of patient discharge from secondary care [ 5 ]. Electronic systems are, not without their limitations, having been shown to lead to ‘sociotechnical errors’, defined as those ‘occurring at the point where the system and the professional intersected and would not have occurred in the absence of the system’ [ 6 ]. In the UK, implementation of electronic prescribing systems is variable. A survey of English hospitals in 2011 reported that while 48% of hospitals had implemented standalone electronic discharge systems, only 13% had implemented integrated inpatient and discharge electronic prescribing [ 7 ]. Reduction in inpatient prescribing errors has been demonstrated with electronic prescribing systems [ 8, 9 ]. However, there has been limited study of prescribing error alteration in discharge prescriptions. A narrative literature review of discharge information communication and medicines discharge prescribing errors identified four studies comparing electronic solutions to traditional handwritten systems and five of electronic solutions with no comparison. These studies demonstrated inconsistent results with improved, unchanged or reduced medicine information accuracy [10]. Notably, none of the study sites had implemented the UK HEPMA sys (...truncated)


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Pamela Ruth Mills, Anita Elaine Weidmann, Derek Stewart. Hospital electronic prescribing system implementation impact on discharge information communication and prescribing errors: a before and after study, European Journal of Clinical Pharmacology, 2017, pp. 1-8, DOI: 10.1007/s00228-017-2274-7