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

28 Medication Administration and Information Technology 363
Standalone eMARs surprisingly do not change the cognitive workflow of
nurses, 31 who must still go through the outlined steps to assure the “five rights.” The
principal exception may be increased time in checking or verifying medication doses
(which may require computerized sign-off by a colleague). 32 Nursing satisfaction
with the fit of the technology into workflow and its acceptance are essential, and
perceptions of ineffective technology may induce overrides and workarounds (“first
order problem-solving” 33 ) that defeat the purpose of the technology.
Linkages of eMARs to bar-coding provide functionalities of positive
identification of patient wristbands to drug doses, double-checking of dose times
and interception of errors. 34 The incorporation of these into an inpatient closedloop
(end-to-end integrated medication cycle) system has been shown to reduce
prescribing and administration errors, increase patient identity confirmation prior
to administration and increase time required for task completion. 35
Successful adoption, deployment, and use of eMARs depends on many human
and organizational factors, including nursing leadership (particularly at the level
of the clinical care unit) that is aligned with institutional leadership that promotes
HIT as a path to patient safety and the presence of clinical nurse champions, 36 sufficient
nursing education and technical support. Understanding nursing resistance
to adoption 37 may give directions to efforts to improve it. Structured educational
programs must provide nurses with (a) an overview of the incorporation of HIT
(such as eMARs) into medication administration and how it will change their work,
(b) hands-on training with tools that uses scenarios that match the particular user’s
work tasks and (c) an opportunity to demonstrate competence via simulation.
Monitoring and evaluation of problems occurring at deployment 38 and in
operation 39 may provide data for further refinements to the system. Problems, when
reported, may arise from: lack of staff knowledge about the patients, medications,
equipment (including system capabilities) or procedures; failure to follow correct
procedures or lack of standard protocols; failures of communications or transcription;
or systems issues.
Particular administration problems may persist: where dual medication administration
records (paper and electronic) exist, requiring duplicate entry and the
opportunity for errors 34 ; during patient transfers between institutions 40 care units
(where duplication or omission of doses may occur) 41 and in domains where care is
complex (such as pediatric cancer chemotherapy). 42
28.5 Conclusion
Medication administration is a step in the medication delivery cycle that is vulnerable
to errors. Health information technologies may help to mitigate some of the
vulnerabilities, but it is still a largely human controlled process, even with closedloop
applications. Even with reductions in prescribing errors, there remains much
work to be done in reducing medication administration errors.