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

25 Overview of Pediatric Inpatient Medication Delivery 333
“Dispensing” is the provision of drugs with the prescribed instructions (to either
a patient or an intermediary) for administration. In institutional ambulatory settings,
the pharmacy is increasingly required to manage free samples provided by drug
sales representatives. In inpatient settings, dispensing includes proper checking,
packaging, and labeling of doses and instructions, time delivery, proper storage
until administration, and auditing of handoffs from pharmacy staff to nursing. The
compounding/dispensing step is complete when a patient’s nurse accepts the medication
dose and its instructions for that patient from the pharmacy.
Administering/Monitoring (Chapter 28): “Administering” a drug dose is the
last step in delivering a prescribed medication regimen to a patient. It includes
understanding of dosing instructions by the patient or an intermediary (in inpatient
settings, this may be the nurse). It also includes any final preparation or manipulation
of the drug dose (such as mixing with an intravenous carrier) and assurance
of delivery (direct observation of oral therapy, intravenous line checking). The
administering step is complete when all necessary steps are completed and the dose
administration has been documented in a medication administration record.
“Monitoring” is an intrinsic safety function (and the most important part) of
medication use. In the ambulatory setting, adverse drug events are based on patient
reports and clinical findings. In inpatient settings, nurses and primary care providers
document drug effects (favorable and adverse) in the patient record. Adjunct
reporting systems track adverse events and reactions for research, and for quality
and safety improvement.
Documenting: “Documenting” a drug dose is the creation of a formal record of
each of the steps involved in medication use for archiving and for retrieval for
clinical and administrative use. This function is an automatic function in HIT
applications.
The medication use model emphasizes cognitive and physical activities
of the various roles, including communication and record-keeping functions.
Improvement of the safety and reliability of the medication use process, and the
reduction of process errors, involve analysis of where the model can fail—with
what probabilities and with what impacts. One approach to “failure modes analysis”
asks the “five wrongs”: how frequently and with what impacts do the “wrong
drug” or the “wrong dose” via the “wrong route of administration” to the “wrong
patient” have? Failure mode and effects analysis is discussed in Chapter 29.
25.3 Automation and Computerization to Improve Safety
Past and current experience in health care (and other industries) suggests that
complex and error-prone patient care activities such as the medication process can
be reengineered to reduce errors and increase safety through the use of automation
and computerization to standardize and streamline work. In prescribing/ordering,
computerized provider order entry (CPOE) and clinical decision support (CDS)
have been shown to reduce prescribing errors in complex processes such as neonatal
parenteral nutrition and continuous infusions (Chapter 26); in compounding/