Abstract
This paper analyzes the use of various technologies in nursing care and whether these technologies improve patient safety. It will review various computer technologies such as EHR and CPOE, automated dispensing cabinets, point of care testing and intravenous smart pumps. Various studies support the use of these technologies in improving patient safety and increasing efficiency in nursing care. From removing the human factor of poor penmanship in charting, to reducing transcription errors and dispensing errors around medication administration. In the face of improved patient safety, there are, unfortunately, some shortcomings to these technologies, such as user error and overrides which can negatively impact patient safety. These shortcomings can be corrected with the appropriate interventions.
Introduction
Our lives are constantly being besieged on a daily basis of “things happening”. Whether it be acts of nature such as earthquakes, fires, floods, or other acts that are beyond our control, things simply happen. In healthcare “things happen” as well, nearly 20 years ago in the U.S it was reported that there were as many as 98,000 deaths annually as a result of preventable medical errors (Ehrmeyer, 2011). We cannot control negative events such as acts of nature; however, in the area of nursing, are there changes that can be made to help reduce such medical errors and improve on patient safety? That is the topic that will be up for discussion in this paper. In regard to patient safety, “Does technology in nursing help to improve patient safety?”. In this paper, we will explore various technologies that have been implemented over the last decade or so and what kind of benefits they provide to improving on patient safety. We will also scrutinize any potential downfalls of certain technologies that can become unintended consequences of trying to improve on patient safety. Technologies such as electronic health records, computerized physician order entry and other programs associated, as well automated medication dispensing systems, point-of-care testing, and intravenous smart infusion pumps.
Significance
Patient safety and improved patient outcomes are unquestionably paramount in nursing. The nursing field plays a tremendously large role in healthcare so it would be critical to ensure that any means available be used to assist in improving upon patient safety in nursing. Technology is the present and future as it provides potential means to evolve healthcare towards meeting that goal of improving patient safety.
Computer Technologies
In healthcare today, various information technologies have provided a foundation for the future. The way healthcare has become modernized is best envisioned if we look back and compare how we were some thirty years ago. Paper and lots of it have been gradually replaced with computers over the last three decades. Although some healthcare facilities still rely on dated paper charting, most have moved forward and have adopted new computer technologies.
Electronic Health Records or “EHRs” are the most commonly used technology. EHR is defined by Menachemi & Collum, (2011) as “a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports.” One of the primary benefits of the EHR revolves around the simple elimination of poor penmanship which has plagued the paper medical chart. The leading problem with paper charting was the ability or inability to read handwritten notes, anyone familiar with traditional paper charting can attest to the challenge of having to read someone’s writing. In nursing, it is important to be able to read past progress notes. Whether it be to see the progression of the patient, to review planned or failed interventions or to simply get a better understanding of your patients stay in the hospital. The inability to read notes because of poor writing skills can have a negative outcome on the patient which is why the EHR is so beneficial. EHRs have other advantages; they can create many efficiencies in the delivery of care which allows more time spent on patient care which in turn can improve on safety (Menachemi & Collum, 2011). They also have the advantage of being able to better conduct research which can promote improved population health (Menachemi & Collum, 2011). One study that followed the outcomes of older adults found that the EHR was associated with an improvement in documentation for pressure ulcer risk assessments which in turn demonstrated a 13% reduction in hospital acquired pressure ulcers (Bowles et al. 2015).
Often used in conjunction with the EHR is the computerized physician order entry system or CPOE. The CPOE allows physicians or other providers to electronically enter orders, such as medications, laboratory tests or radiology requests (Bowles et al. 2015). Much the same as with the EHR, the CPOE eliminates the “poor penmanship” factor significantly reducing the number of dangerous medical errors such as medication errors. A study noted by Bowles et al. (2015) found that serious medication errors can be reduced by nearly 55% when a CPOE is used alone. That reduction can be increased to 83% when combined with a CDS, which we will explore shortly. This reduction is predominately due to a reduction in transcription errors such as poor handwriting, vague or unclear abbreviations and lack of knowledge by the ordering physician (Khanna & Yen, 2014). Another study found that the probability of a prescribing error was reduced by 48% in comparison to paper-based orders (Khanna & Yen, 2014).
The CDS, or “clinical decision support” is a tool that supports the clinician in making decisions with regard to patient care. It can provide the latest information on patient allergies or provide alerts to drug interactions, and reminders on prophylactic care (Menachemi & Collum, 2011). A study discussed by Menachemi & Collum. (2011) indicated that the CPOE system with CDS could provide alerts to anticoagulation prophylaxis. This in turn translated to a 41% reduction in deep vein thrombosis or pulmonary embolism at 90 days post discharge.
Although the CPOE and CDS are not tools used directly by nurses, but rather physicians, the resulting benefits of using such systems provide an increase in patient safety. The simple elimination of the human factor, poor handwriting that is, is a key benefit which in turn allows the nurse to provide more accurate and safer care to their patients. The EHR which is used by nurses provides another improvement in patient care thus improving on patient safety. Despite these improvements in patient care and safety, there are some drawbacks to such systems which could be seen to negatively impact patient safety. The sheer complexity of implementing such systems can cause safety hazards in their early adoption as users learn and adjust to such a significant change in their work flow (Khanna & Yen, 2014). Another drawback to these systems is that some systems have been found to add additional tasks and increase in cognitive load on the clinician. This in turn decreases efficiency and consequently raise the risk of making an error (Khanna & Yen, 2014).
Automated Dispensing Cabinets
As discussed previously, the CPOE has been shown to reduce medication transcription errors and the CDS can assist the clinician in providing alerts to drug interactions and drug interactions. The automated dispensing cabinets, or ADC, can add to that level of safety when it comes to medication administration. An ADC is a computer controlled medication storage system that allows medications to be stored, dispensed, documented and tracked. It allows medications to be selected from a patient profile based on the medications listed on the patient’s e-MAR or MAR and dispensed from locked drawers. Various studies have supported the use of the ADC as a means to reduce medication errors. An observational study following the use of an ADC in two ICU’s observed that compared to the control unit, there was a reduction in total opportunities for error by 26% (Chapuis et al. 2010). Another study reviewed various other studies of unit-based ADC use and found that dispensing errors and medication errors were reduced by 30-40% (Rochais et al. 2014). Nurses also find benefits to an ADC that assist in providing safer and more efficient care. They report that they eliminate or reduce the delays due to medication availability, missing doses and allow the pharmacist to review medication orders prior administration (Mandrack et al. 2012). An ADC also provides an added level of safety with computerized alerts such as high-alert medications, or alerting to not administer the full dose should a pill require cutting. For narcotic administration the ADC can provide an alert to confirm immediate release vs long-acting. Alerting the nurse to a hazardous drug is another critical safety measure of the ADC. A warning for cytotoxic medications can assist the nurse as a reminder that the patient they are caring for is or could be cytotoxic. This can ensure the nurse has taken the appropriate cytotoxic precautions not only for themselves, but for co-patients who may be sharing a bathroom in a semi-private room.
A bar-code e-MAR can add to the margin of safety provided by the ADC by forcing the user to use a bar-code verification prior to administering medications. One study by Poon et al. (2010) concluded that this method provided a 41.1% reduction in errors in medication administration and a 50.8% reduction in adverse drug events.
Despite these significant patient safety improvements provided by the ADC and bar-code e-MAR, there are still some risk factors involved with their use. Manual overrides are a key concern where nurses can override a medication that has not been reviewed by the pharmacist, or lack of alerts to warn of a medication having already been administered (Mandrack et al. 2012).
Point of Care Testing
Point of care testing or POCT is a widely used technology, albeit perhaps not as important as the other technologies discussed thus far when it comes to patient safety. POCT is defined as any testing that is conducted outside the central clinical laboratory and instead right near the patient, such as the bedside (Ehrmeyer, 2011). The most common type of POCT is blood glucose monitoring. The benefits to POCT for blood glucose monitoring is the ability to obtain an immediate result so that the appropriate nursing intervention can be performed. Although there does not appear to be an added benefit to patient safety using this technology, it can however provide more efficient care to the patient. In spite of the improved efficiency, there are several concerns with POCT related to “human process factors” (Ehrmeyer, 2011). There is a risk of an incorrect result due to user error, and not performing the daily quality control testing to ensure proper calibration (Ehrmeyer, 2011). Other factors such as lack of ongoing competency can result in misuse.
POCT may not be the technology that helps nurses improve on patient safety, but it does allow nurses to perform their job more efficiently. This may allow more time with each patient. User competency, quality testing, education and leadership are key factors in ensuring that POCT is safe for the patient.
Intravenous (IV) Smart Pumps
IV pumps are rather mainstream in nursing these days, perhaps something that can be taken for granted in most acute care facilities. Smart IV pumps have replaced the old method of gravity drips where the nurse needed to take time to calculate the drip rate. Although it worked, it was inefficient and lacked accuracy. The smart IV pump on the other hand eliminates that by making IV infusions fast and accurate, but that is not the primary benefit of this technology. The key benefit of smart IV pumps is in their increase level of safety for the patient. These IV pumps store vast drug libraries and dose error reduction systems that significantly reduce programming errors which in turn reduces medication errors. These pumps ensure that the proper medication and diluent are being used, that the maximum infusion rate is not exceeded and can alert to any programming errors. All these help to maximize patient safety. A study by Ibarra-Perez et al. (2017) concluded that the use of smart IV pumps prevented a significant amount of adverse drug events in relation to drug dosing. These findings were echoed by Ohashi et al. (2014), they found a reduction in wrong rate, wrong dose errors while reducing adverse drug events.
Like other technologies, these studies did point to the fact that overrides and work arounds do pose a concern. However, overall these smart IV pumps add significant safety to patient care.
Conclusion
Technology in the field of nursing and healthcare in general is clearly beneficial to patient safety. Computer technologies like the EHR improve documentation and allow easier more efficient access to patient information, while the CPOE when used in conjunction with CDS reduce medication transcription errors. Both of these technologies remove the human factor of poor penmanship, all which help to improve patient safety. The ADC reduce medication dispensing errors, provide necessary alerts for high-alert medications and ensure better collaborating with the pharmacist prior to administration, all to the benefit of patient safety. IV infusion pumps also help to reduce dosing errors and other adverse drug events while adding efficiency to patient care. POCT may not add much to patient safety, however it provides more efficient and faster treatment to the patient. All these technologies have been proven to add to patient safety, however as mentioned before, there are some drawbacks. User error, overrides, work arounds and lack of education or competence add risk to patient care. These risks though can be reduced with proper leadership and education which will only add to the important factor of patient safety.