Pediatric Informatics: Computer Applications in Child Health (Health ...

8 Complexity in Healthcare Information Technology Systems 107
Efficient verbal communication can solve this problem only partially. The
required scheduling of a medication at ordering remains unsolved. Traditionally,
nurses have been in charge of these tasks. 69 Physicians are usually unaware of
important information required to schedule a task: (1) order schedules are often
inconsistent with the other medications on the MAR, or would require the nurse to
wake the child unnecessarily, or must be changed due to vascular access problems;
(2) scheduled procedures; (3) family situations such as breast feeding or “skin to
skin” encounters, and; (4) the need to coordinate one patient’s care with a second
patient assigned to the same nurse, or, with; (5) other bedside processes (e.g. auditory
screening, ultrasounds, etc.).
These medication “scheduling” conflicts were easily resolved on paper, when
nurses had the authority to reschedule doses as needed, or to call physicians or
pharmacies to negotiate amended orders. On paper, nurses were looking at the
original, official version of the orders, and could physically apply an amendment.
For time critical orders (i.e. for platelets), the negotiation might require workflow
changes in other departments’ workflow (e.g. the blood bank). In these situations,
effort is reduced and accuracy improved with end-to-end synchronous communication
in a single system between the bedside nurse and involved ancillary
staff. In CPOE, a physician’s offsite orders that conflict with bedside schedules
and situations cannot easily be amended by other providers thus causing delay in
medication administration and additional work to alter the medication administration
workflow.
8.3.5.2 Medication Reconciliation
The best human/computer system interaction process is for medication reconciliation
is currently unclear. Traditionally “reconciliation” occurred at the bedside once
per shift, between two nurses reviewing all the orders (of all types) in chronological
sequence, in the paper chart, while checking all the medications, tubes, and other
equipment at the bedside. CPOE increases the possibility of missed orders due to
poor screen display, order fragmentation, and poor temporal sequencing of reports.
A full electronic MAR with fully developed temporal reasoning capabilities that
can be installed and integrated with other medication-related hospital information
utilities (i.e. blood bank, laboratory, supply chain, and nutritional product management)
is urgently needed for children undergoing inpatient care. Without such an
eMAR, increased risks of “new types” of medication errors from partially inte-
67, 70
grated, adult designed, add-on systems will persist.
8.3.5.3 Unit of Measures
Correct and appropriate units of measure are critical in Pediatric medication
ordering. Particular attention must be paid to the default ordering unit of measure,
and to the proper unit of measure conversion calculations. In adults, Ampicillin is