Procedural Error Identification in Ward-based Drug Administration            with RFIDBryan Houliston                     ...
Contents   1    Adverse Drug Events   2   Ward-based dispensing   3   BCMA and workarounds   4       Smart Drug Tray   5  ...
Adverse Drug Events• 151 deaths, 4871 injuries per year in NZ                                        (Johnston, 2007)• Est...
‘Five Rights’• Right patient• Right drug• Right dose• Right time• Right route
Ward Dispensing Errors - Scope• 86 ward dispensing activities  – 79 potential errors                (Lane et al, 2006)    ...
Ward Dispensing Errors - Data• From literature review :         (McDowell et al, 2010)  73% of administrations   – Incorre...
Causes of Error• ‘… fatigue, inexperience, and haste are  known generally to increase error  rates…[Open for debate is the...
Importance of Procedure• 50% of AEs result from “system factors”  including lack of procedure or non-  adherence          ...
IT Solutions Enforce Procedure• Right patient• Right drug• Right dose• Right time• Right route ?
Barcode Medication Admin• Scan patient wristband and drug label• Appear to reduce ADEs, if implemented  and used correctly...
If implemented correctly…• Poor implementation leads to  “a lot of overhead because [staff] must  constantly log in and ou...
And used correctly…• Staff routinely work around problems                            (Koppel et al, 2010)  – Barcodes dama...
RFID for BCMA• Radio Frequency Identification  – Readers and tags communicate wirelessly• Advantages over barcodes  – No m...
Existing RFID - Portable• Handheld reader attached to COW                                                (Lai et al, 2007)...
Existing RFID - Embedded• In personal screens           (Bardram et al, 2004)• Ceiling/wall mounted            (Ohashi et ...
In between: Smart Drug Tray• Portable tray with embedded reader• Should be able to  – Warn if drug given before patient id...
Prototype Design• Tray with reader  – Battery powered  – Bluetooth  – Audible and visual    feedback  – Continuous reading...
Evaluation• Reading patient wristbands  – Range  – Through material  – Wristband position• Reading tagged drugs  – Differe...
Battery Life• With  – One read per second  – Bluetooth active  – LEDs and speaker active• Minimum = 4 hours, 50 minutes• A...
Reading Patient Wristbands                         Covered by blanket                                On outside of wristTa...
Reading Tagged Drugs      100%         0%     100%         100%
Reading Tagged Drugs Again               100%       100%                 100%        100%
Reading More Tagged Drugs         99%    100%         15%    0%          97%    0%          46%
Failure to Identify Patient• Simple VB application developed• Demonstration
Further Development• Some work before user evaluation  – Raising alarms – beeps, LEDs  – Fully embed reader  – Embed secon...
Conclusion• ADEs cost lives and resources• Improving adherence to procedures may  reduce ADEs• BCMA systems are routinely ...
ReferencesBardram JE. Applications of Context-Aware Computing in Hospital Work - Examples and     Design Principles. Sympo...
ReferencesLane R, Stanton NA, Harrison D. Applying hierarchical task analysis to medication    administration errors. Appl...
Upcoming SlideShare
Loading in …5
×

Procedural Error Identification in Ward-based Drug Dispensing via RFID

868 views

Published on

Bryan Houliston
AURA Laboratory, School Of Computing and Mathematical Sciences, Auckland University of Technology
(Thursday, 3.00, Science 1)


Published in: Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
868
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
0
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide
  • McDowell et al found nine studies from 2000-2009, all from European hospitals.‘Not identifying patient’ was only considered in two of those studies, and no instances were recordedWestbrook et al observed nurses in Australian hospital‘Incorrect dilutio’ was 4th most common clinical error
  • (Johnson, 2007) reporting Ministry of Health estimatesTwo recent high-profile cases: MervynMcAlpine – given wrong medication after another patient’s records attached to hisEileen Anderson – given wrong medication after someone else’s name sticker put on her chart
  • (Lane et al, 2006) Hierarchical Task Analysis of ward-based dispensingRetrieval / Checking relate to information, on patient, drugs, proceduresSelection / Action relate to carrying out activityWestbrook et al observed nurses in Australian hospital‘Incorrect dilutio’ was 4th most common clinical error
  • McDowell et al found nine studies from 1995 - 2005, all from European hospitals.‘Not identifying patient’ was only considered in two of those studies, and no instances were recordedWestbrook et al observed nurses in Australian hospital‘Incorrect dilution’ was 4th most common clinical error
  • (Westbrook et al, 2010) 53% of drug administrations were interrupted
  • (Koppel et al, 2010) - thousands of patient scans and medication scans failed because the barcode labels were crinkled, smudged, chewed, torn, had liquid spilled on them, or were covered by other labels. Almost 100 patient scans failed because patients were asleep, breastfeeding, being bathed, or in some other position where the barcode was not visible without disturbing the patient. As a result nurses routinely scanned copies of patient identification barcodes kept on drug trolleys, on doors, on their belt rings, and other more convenient locations. In doing so, the likelihood of a patient being misidentified are clearly increased.
  • (Koppel et al, 2010) - thousands of patient scans and medication scans failed because the barcode labels were crinkled, smudged, chewed, torn, had liquid spilled on them, or were covered by other labels. Almost 100 patient scans failed because patients were asleep, breastfeeding, being bathed, or in some other position where the barcode was not visible without disturbing the patient. As a result nurses routinely scanned copies of patient identification barcodes kept on drug trolleys, on doors, on their belt rings, and other more convenient locations. In doing so, the likelihood of a patient being misidentified are clearly increased.
  • (Lai et al, 2009) – Essentially replicating BCMA but with RFID instead of barcodes(Bravo et al, 2008) – Phones use NFC, hence effectively only work at ‘touch’ range
  • Distance is the maximum that produced a read rate of 80% or greater.‘Covered by blanket’ did get individual reads up to 60 cm
  • Blind spot at the bottom of the reader
  • Syringe drops from 100% to 46%Glass vial only 15%Foil pack and tube both 0%
  • Procedural Error Identification in Ward-based Drug Dispensing via RFID

    1. 1. Procedural Error Identification in Ward-based Drug Administration with RFIDBryan Houliston Rob TicehurstDave Parry Aura Laboratory
    2. 2. Contents 1 Adverse Drug Events 2 Ward-based dispensing 3 BCMA and workarounds 4 Smart Drug Tray 5 Conclusion
    3. 3. Adverse Drug Events• 151 deaths, 4871 injuries per year in NZ (Johnston, 2007)• Estimated 20% of public health spending due to AEs (Ministerial Review Group, 2009)
    4. 4. ‘Five Rights’• Right patient• Right drug• Right dose• Right time• Right route
    5. 5. Ward Dispensing Errors - Scope• 86 ward dispensing activities – 79 potential errors (Lane et al, 2006) Selection Read Administer chart drugs Retrieval Action Prepare drugs Checking by dispensing stage by type of activity
    6. 6. Ward Dispensing Errors - Data• From literature review : (McDowell et al, 2010) 73% of administrations – Incorrectly diluted 31%• From observation : (Westbrook et al, 2010) 74% have ‘procedural’ error – Not identifying patient 59% 25% have ‘clinical’ error – Drug given at wrong time 64%
    7. 7. Causes of Error• ‘… fatigue, inexperience, and haste are known generally to increase error rates…[Open for debate is the] question of whether the chance of an error at some later stage is dependent on occurrence of an error at an earlier stage’ (McDowell et al, 2010)• Do procedural errors make clinical errors more likely?
    8. 8. Importance of Procedure• 50% of AEs result from “system factors” including lack of procedure or non- adherence (Davis et al, 2003)• 28% of drug errors result from ‘procedure / protocol not followed’ (Hicks & Becker, 2008)
    9. 9. IT Solutions Enforce Procedure• Right patient• Right drug• Right dose• Right time• Right route ?
    10. 10. Barcode Medication Admin• Scan patient wristband and drug label• Appear to reduce ADEs, if implemented and used correctly (Poon et al, 2010)
    11. 11. If implemented correctly…• Poor implementation leads to “a lot of overhead because [staff] must constantly log in and out of devices at hand, starting and stopping sets of applications, and browsing each to present the proper view for alternating activities” (Bardram & Christensen, 2007)
    12. 12. And used correctly…• Staff routinely work around problems (Koppel et al, 2010) – Barcodes damaged, faded, obscured – Patient in wrong position – COWs unwieldy, limited battery
    13. 13. RFID for BCMA• Radio Frequency Identification – Readers and tags communicate wirelessly• Advantages over barcodes – No markings to smudge, fade – Don’t need line of sight – Tags have unique ID numbers
    14. 14. Existing RFID - Portable• Handheld reader attached to COW (Lai et al, 2007)• Phones with NFC (Bravo et al, 2008) – Short range = risk of nosocomial infection (Ulger et al, 2009)• Nurse has to drive application
    15. 15. Existing RFID - Embedded• In personal screens (Bardram et al, 2004)• Ceiling/wall mounted (Ohashi et al, 2008)• Application detects nurse activity and drives itself
    16. 16. In between: Smart Drug Tray• Portable tray with embedded reader• Should be able to – Warn if drug given before patient identified – Know patient wristband has been read – Know when drug removed from tray• Should not – Tethered to COW – Very short range – Require nurse to drive
    17. 17. Prototype Design• Tray with reader – Battery powered – Bluetooth – Audible and visual feedback – Continuous reading• Patient wristband – UHF tag• Tagged medication containers
    18. 18. Evaluation• Reading patient wristbands – Range – Through material – Wristband position• Reading tagged drugs – Different containers – Location on tray• Detecting failure to identify patient• Battery life
    19. 19. Battery Life• With – One read per second – Bluetooth active – LEDs and speaker active• Minimum = 4 hours, 50 minutes• Average = 6 hours, 20 minutes
    20. 20. Reading Patient Wristbands Covered by blanket On outside of wristTag state On top of wrist On inside of wrist On bottom of wrist 0 10 20 30 40 50 60 70 80 Distance (cm) for 80+% read rate
    21. 21. Reading Tagged Drugs 100% 0% 100% 100%
    22. 22. Reading Tagged Drugs Again 100% 100% 100% 100%
    23. 23. Reading More Tagged Drugs 99% 100% 15% 0% 97% 0% 46%
    24. 24. Failure to Identify Patient• Simple VB application developed• Demonstration
    25. 25. Further Development• Some work before user evaluation – Raising alarms – beeps, LEDs – Fully embed reader – Embed second reader• Further checks for procedural errors – All medications given – Medications correct for patient – Time correct
    26. 26. Conclusion• ADEs cost lives and resources• Improving adherence to procedures may reduce ADEs• BCMA systems are routinely worked around• RFID enables easier reading of patient wristbands• But challenges remain in reading medication containers
    27. 27. ReferencesBardram JE. Applications of Context-Aware Computing in Hospital Work - Examples and Design Principles. Symposium on Applied Computing, 2004.Bardram JE, Christensen HB. Pervasive Computing Support for Hospitals: An Overview of the Activity-Based Computing Project. Pervasive Computing. 2007;6(1):44-51.Bravo J, Hervas R, Fuentes C, Chavira G, Nava SW. Tagging for Nursing Care. Second International Conference on Pervasive Computing Technologies for Healthcare; Tampere, Finland: IEEE; 2008.Davis P, Lay-Yee R, Briant R, Ali W, Scott A, Schug S. Adverse events in New Zealand public hospitals II: preventability and clinical context. New Zealand Medical Journal. 2003;116(1183).Hicks RW, Becker SC. An Overview of Intravenous-related Medication Administration Errors as Reported to MEDMARX, a National Medication Error-reporting Program. Journal of Infusion Nursing. 2006;29(1):20-7.Johnston M. Wired for saving lives. Weekend Herald, August 25. 2007;Sect. B4. Koppel et al, 2010Lai C-L, Chien S-W, Chang L-H, Chen S-C, Fang K. Enhancing Medication Safety and Healthcare for Inpatients Using RFID. Portland International Center for Management of Engineering and Technology Conference; Portland, Oregon: IEEE; 2007.
    28. 28. ReferencesLane R, Stanton NA, Harrison D. Applying hierarchical task analysis to medication administration errors. Applied Ergonomics. 2006;37(5):669-79.McDowell SE, Mt-Isa S, Ashby D, Ferner RE. Where errors occur in the preparation and administration of intravenous medicines: a systematic review and Bayesian analysis. Quality and Safety in Health Care. 2010;19(4):341-5.Ministerial Review Group. Meeting the Challenge: Enhancing Sustainability and the Patient and Consumer Experience within the Current Legislative Framework for Health and Disability Services in New Zealand. Wellington, 2009.Ohashi K, Ota S, Ohno-Machado L, Tanaka H, editors. Comparison of RFID Systems for Tracking Clinical Interventions at the Bedside. American Medical Informatics Association Annual Symposium; 2008 8-12 November; Washington, DC.Poon et al, 2010Ulger F, Esen S, Dilek A, Yanik K, Gunaydin M, Leblebicioglu H. Are we aware how contaminated our mobile phones with nosocomial pathogens? Annals of Clinical Microbiology and Antimicrobials. 2009;8(7).Westbrook JI, Woods A, Rob MI, Dunsmuir WTM, Day RO. Association of Interruptions With an Increased Risk and Severity of Medication Administration Errors. Archives of Internal Medicine. 2010;170(8):683-90.

    ×