Automation can reduce errors, but don’t jump before looking, ISMP says
Automation can reduce errors, but don’t jump before looking, ISMP says
Automation may not be a universal remedy for preventable adverse drug events, even though it can play a major role in reducing errors, says the Institute for Safe Medication Practices (ISMP), a nonprofit organization in Huntingdon Valley, PA. The group cautions providers to look carefully before adopting such a system.
In a recent statement, the ISMP addressed computerized physician order entry, electronic medication administration records, bar code systems, and other automated systems designed to eliminate medication errors. In the recent debate over medical errors, such automated medication systems have been called a possible solution to drug errors. The ISMP says, however, that "while such technology is pivotal to reducing errors, too often, health care leaders mistakenly believe that the immediate effects of automation alone will ensure the safety of their medication systems."
Accommodating the technology
The ISMP reports that early adopters of the newest technology have reported significant barriers to successful implementation, new sources of error, and major infrastructure changes that have been necessary to accommodate the technology. The group also says some vendors have marketed their products without sufficient testing or the ability to fully implement it on site.
"As a result, frustrated practitioners have taken shortcuts or added complexity to the medication system to circumvent or cure technology problems," the ISMP says.
For example, because there is no a uniform bar code required on all products, the error-prone process of in-house packaging and coding may be necessary when implementing bar-coded drug administration. Even with bar-coded drugs, nurses may be unable to scan the drug at the bedside if it must be removed from its package for preparation. Also, if a drug is prescribed or entered into the pharmacy computer in error, bar-code systems will only help get the wrong drug to the correct patient or the ordered drug to the wrong patient.
The ISMP also points out that automation does little to enhance medication systems that are already plagued with problems. "For example, using robotics for drug dispensing in systems without timely order entry and interfaces for transfers, admissions, and discharges, is fraught with error. Placing automated dispensing cabinets in systems with slow turnaround time for medications dispensed from pharmacy will likely lead to increased stock and unsafe administration of many first doses without pharmacy screening," the ISMP reports.
For the ISMP, automation seems only a limited solution. The group suggests that while health care should embrace automation, "we should do so with our eyes wide open, recognizing its potential to introduce new and unrecognized sources of error into the system." The most important point, the ISMP says, is that you should "not place sole emphasis, resources, and reliance on automation while sacrificing or ignoring other safety initiatives that can reduce the likelihood of medication errors, as automation alone is not the panacea for medication errors that some believe it to be."
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