Problem: Technology advised to advance assurance and adeptness occasionally produces abrupt error-prone conditions. Such is the case with an adjustment administering scanning arrangement (OMSS), which captures a agenda angel of a handwritten or printed adjustment and routes it to the pharmacy, appropriately eliminating the charge for faxing, courier, or aeriform tubing systems. The advantages of such technology are abundant and include: decreased time for the adjustment to adeptness pharmacy; decreased turnaround time from prescribing to availability of medications for administration; cyberbanking filing, maintenance, and accessible retrieval of scanned orders in the pharmacy; affidavit of quality-associated comments with the use of highlighting and notations; and, potentially, a lower blow of archetype errors back ambiguous areas of the adjustment can be enlarged. Unfortunately, these advantages are compromised if the pharmacy never receives the orders—a action that exists back assorted pages of orders are pulled through the scanner at the aforementioned time, appropriately scanning alone a distinct folio into the system. The aforementioned botheration can action back faxing or artful orders for pharmacy. Agents on the assemblage who scanned the abstracts may be blind of what happened and accept all orders were scanned and beatific to pharmacy. The pharmacy agents are additionally blind that they should accept accustomed assorted pages of orders in their workflow queue. Consequently, important biologic analysis may be missed, as declared in the afterward contempo event.
A physician wrote three pages of acceptance orders for a lung blight accommodating with C. difficile colitis and fever. The orders were scanned application the OMSS and accustomed by pharmacy, but one of the pages was pulled through the scanner forth with accession page. Thus, the pharmacy alone accustomed two pages of the orders. The pharmacist did not apprehension that one folio of the acceptance orders was missing, nor did the assistant who arrested the computer-generated medication administering almanac (MAR). The patient’s physician did not apprehension the absurdity either, as he did not commonly analysis the patient’s MAR. Several access medications were assigned on the missing folio of orders. By the fourth day of admission, the accommodating apparent camp behavior and developed abashing and hypoxia. A rapid-response aggregation was alleged and bent that the accommodating may accept accomplished a seizure. The accommodating was transferred to a analytical affliction assemblage breadth his action worsened, acute intubation. Back the biologic levels of his assigned anticonvulsants were appear as low, the physician apparent the error. Later, the accommodating was auspiciously extubated and absolutely recovered.
While investigating this event, the antecedent almost account was anticipation to be that the assistant bootless to browse the missing folio of orders to pharmacy. However, because the hospital had encountered missing pages of scanned orders before, agents bound accomplished that the missing folio had ashore to one of the added pages during the scanning process. In fact, back January 2006, 16 scanning errors that led to medication omissions—some for the absolute analysis of the patient—had been appear in the hospital; four of these errors occurred in 2009. Although no patients were actively afflicted because of these above-mentioned events, abounding of the omissions were potentially adverse and appropriate intervention.
For example, a accommodating with abiding adverse pulmonary ache (COPD) absent articulate doses of aspirin and intravenous doses of furosemide and levofloxacin for 2 canicule afterwards acceptance because alone four of the six pages of acceptance orders were accustomed in the pharmacy via the OMSS. Accession COPD accommodating absent doses of methylPREDNISolone and cefTRIAXone for 2 canicule and accomplished chest affliction acute nitroglycerin due to respiratory problems back alone three of the four pages of acceptance orders were accustomed in the pharmacy via the OMSS. A actively ill accommodating with pneumonia didn’t accept antibiotics for 3 canicule back one of the three pages of a preprinted adjustment set was not accustomed in the pharmacy. A accommodating accepted with pulmonary array accustomed the aboriginal dosage of enoxaparin in the emergency department, but two consecutive doses 12 hours afar were not accustomed because the medication adjustment was on a folio that was ashore to accession folio of acceptance orders while actuality scanned. According to the pharmacist who appear these problems to ISMP, the 16 accurate cases represent aloof the tip of the iceberg, as best instances of missing scanned adjustment forms were captured and adapted by a pharmacist or assistant afore an blank occurred. In fact, the anchorman estimates that anniversary pharmacist on assignment catches, on average, one instance of a missing folio of orders per day acquired by affairs assorted pages through the scanner at the aforementioned time. Several weeks ago, one pharmacist bent three missing scanned pages during a distinct weekend shift.
In 2007, nurses at this hospital started to certificate the adjustment cardinal provided on the MAR (generated by the pharmacy computer system) abutting to the aboriginal medication adjustment on the patient’s blueprint back acceptance MARs (meaning they could not verify an adjustment unless pharmacy had entered it and produced an adjustment number). While this helped considerably, the arrangement is not foolproof and problems abide to happen.
ISMP contacted three of the better companies that action OMSS—CareFusion (Pyxis Connect), McKesson (Horizon MedComm-Rx), and Omnicell (OmniLinkRx)—to ensure they are acquainted of the botheration of scanners affairs assorted pages through while alone the top folio is actuality scanned into the system. In accession to possibly abstraction too abounding pages into the scanner, the companies provided the afterward accessible causes of this problem:
Moisture or changeless electricity can account pages to adhere to anniversary other
Staples on forms, bankrupt or channelled forms, forms with adhering areas, or absorbed perforated forms may stick to anniversary other
Low-weight cardboard may stick calm (although it is alien whether thicker cardboard prevents the problem)
Worn or bedraggled scanner rollers.
Safe Convenance Recommendations: If you use OMSS at your facility, an interdisciplinary aggregation of front-line nurses and pharmacists should accommodated to plan how to abate the blow of austere biologic analysis omissions acquired by affairs assorted pages through the scanner at the aforementioned time. One important ambition is to annul abundance and admonish individuals that they are scanning absolute important abstracts to the pharmacy. Accede the afterward suggestions, abounding of which additionally administer back faxing or authoritative copies of orders.
Prepare pages. Afore scanning any adjustment form, abolish staples and accessible any bankrupt or channelled sections of the form. Avoid the use of perforated physician adjustment forms back possible.
Limit the pages. Place the scanner aural arm’s adeptness of agents who browse the orders, and if feasible, ask them to browse one folio at a time. This will be easier to accomplish if agents apperceive it could anticipate errors. To animate compliance, affectation a abrupt set of “send” instructions and column a sign— Warning: To anticipate medical errors, NEVER augment added than one adjustment breadth at a time! —on/at the scanner. One abeyant downside of this practice, in accession to bargain efficiency, is that anniversary folio of a accumulation of orders for a distinct accommodating may go to a altered pharmacy agents affiliate for entry. Thus, it would be best to architecture your adjustment access arrangement so that one pharmacist handles all orders from a specific accommodating affliction area. Additionally be abiding to cardinal anniversary folio of multiple-page orders for a distinct accommodating (see below).
Number the pages. If there are assorted pages of orders for a distinct patient, nursing agents should cardinal the pages afore scanning them. Almanac the folio cardinal in a constant area on the adjustment breadth that will not baffle with the absolute orders; cardinal anniversary folio sequentially while including the absolute cardinal of pages (e.g., folio 1 of 5, folio 2 of 5); and browse alone one patient’s orders at a time. Ensure that all multi-page, preprinted adjustment sets accept preprinted folio numbers on them in the aforementioned appearance (e.g., folio 1 of 5). For hospitals that already brand anniversary scanned order, change the brand arrangement to state: “Scanned folio __ of __.”
Monitor receipt. Crave the sender to verify the cardinal of pages scanned application the “sent” acceptance feature. Depending on bell-ringer capabilities, a nursing adviser base or “print receipt” affection may be accessible with the scanning accessory for agents to appearance the cardinal of pages that accept been scanned and accustomed in the pharmacy. In some cases, you may be able to appearance the absolute pages that were beatific to the pharmacy or book a archetype of anniversary adjustment that was scanned as validation of receipt. Do not resend the aforementioned adjustment added than already after communicating with pharmacy.
Verify MAR entries. If employing pharmacy-generated MARs, accede allurement nurses to certificate the adjustment cardinal (generated by the pharmacy computer system) abutting to the aboriginal medication adjustment in the patient’s medical almanac back acceptance MAR entries. This helps ascertain any medication orders that accept not been entered by pharmacy.
Check charts. Ensure the processes associated with end-of-shift and 24-hour blueprint checks are able-bodied in their adeptness to ascertain any medication orders that accept not been transcribed assimilate the MAR. The action should absorb comparing the aboriginal orders to the MAR, band by line. If nurses address the pharmacy computer’s adjustment cardinal abutting to anniversary aboriginal medication adjustment on the adjustment anatomy during MAR verification, reinforce with agents administering blueprint checks to attending for medication orders in the blueprint after a agnate cardinal and nurse’s signature.
Review biologic analysis during handoffs. Reports during handoffs in affliction should accommodate a absolute analysis of accepted biologic therapy. Such a report, decidedly at change-of-shift, can advice with the appropriate analysis of instances back about assigned medications—such as antibiotics for an infection—have been bare by accident.
Prescriber analysis of accepted orders. Animate prescribers to analysis a printout (or cyberbanking listing) of accepted medication orders provided by the pharmacy at atomic every 24 hours, or to analysis the antecedent day’s MAR, to advice ascertain omissions in assigned therapy.
Clean the scanners. Afterward the vendor’s instructions, accomplish accepted aliment and apple-pie the scanners’ rollers and lens consistently or added generally if the pages actuality scanned are unclear.
Reduce variability. Standardize the scanners and user configurations so agents who assignment on added than one assemblage will be accustomed with their use.
Empower patients. Animate ailing patients (and families) to allege up if they are not accepting a medication they had been demography at home or a medication their doctor told them they would accept (e.g., antibiotics) in the hospital.
Most of the recommendations aloft crave the user to bethink to backpack out specific processes, decidedly the being scanning the orders to pharmacy. Thus, we accept additionally encouraged vendors of adjustment administering scanning systems to seek solutions to the botheration through technology improvements, as feasible.
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