How can we optimise the use of e-medication systems?

Towfiqu Barbhuiya via


Electronic medication systems are an integral part of ensuring efficient and documented healthcare, however, they can also lead to troubling errors if not optimised correctly. As part of their Health Innovation Series, Professor Johanna Westbrook and her team from PCHSS Research Stream 1.1 have been unpacking some potential avenues for mistakes within these systems and providing evidence-based solutions for ensuring quality patient care.

In an issue about ‘Double dose trouble’, the researchers highlight that when administering midazolam to patients, one of the routes is ‘Intranasal-Both’. While not overtly problematic, there is the potential for double the dose of medication to be incorrectly given to the patient, where the original dose is interpreted as needing to be administered twice, once in each nostril.

To avoid this problem, the authors suggest that the ‘Intranasal-Both’ option should be removed for systemic medication administered through this route, and to also specify a single nostril when appropriate. Alternatively, users of this medication system could also endeavour not to choose this option to prevent any potential confusion.

In another Health Innovation Series focused on prescribing medication through the intravenous route (IV) in an electronic medication system, a similar issue is shown.

Specifically, IV bolus is presented as an option within these systems, which is a rapid IV injection. Importantly however, IV bolus should not be used for some medication or has specialised settings which are appropriate for use. For example, using the IV bolus route for Clindamycin, an antibiotic, may cause hypotension and cardiac arrest in patients.

To reduce the potential of inappropriate use of IV bolus, the authors suggest that the option should be removed altogether for medications where use is not recommended, and that it should not be the default option if it requires specific doses.

It is clear that small changes such as these can make big differences in patient care and safety. The Health Innovation Series helps shine a light on the potential issues in e-medication practices and other healthcare systems, and encourages the continual use of evidence-based practice to improve care delivery and outcomes.

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