PICO Question ResearchCOHP 450

Ryan Pienta

“In long term care (LTC) facilities, how does the use of electronic medication administration records (eMAR),

compared to paper medication administration records, reduce nurse medication errors?”

Literature Search• Search Words:

• long term care facilities, electronic medication administration records, paper medication administration records, health information system, medication errors

• Search Engines:

• Databases: Gale PowerSearch, PubMed, The Cumulative Index to Nursing and Allied Health Literature

• Results

• There were plenty of articles on medication errors in LTC facilities, but not many in regards to using an eMAR.

• I was able to find a systematic review of clinical decision support systems in LTC (similar to an eMAR) and a report following the implementation of eMARs in 5 LTC facilities.

Literature Search

1 (Marasinghe, 2015)

Marasinghe, K. M. (2015). Computerised clinical decision support systems to improve medication safety in long-term care homes: a systematic review. BMJ Open, 5(5), e006539. http://doi.org/10.1136/bmjopen-2014-006539

2 (Sc0tt-Cawiezell et al., 2009)

Scott-Cawiezell, J., Madsen, R., Pepper, G., Vogelsmeier, A., Petroski, G., & Zellmer, D. (2009). Medication Safety Teams' Guided Implementation of Electronic Medication Administration Records in Five Nursing Homes. The Joint Commission Journal On Quality And Patient Safety, 35(1), 29-35. Retrieved from http://0-www.ingentaconnect.com.libcat.ferris.edu/content/jcaho/jcjqs/2009/00000035/00000001/art00005?token=00481cf80eaea2b1240c41333c4a2f7a6c386f573a677376763c5f4f6d4e2224aa860853

Selection Rationale

1 (Marasinghe, 2015)

• I chose this article because as a systematic review, it offered many different views and has a high level of evidence. While is wasn’t directly focused on eMARs, it included all types of computerized clinical decision support systems and how they improved medication safety in LTC facilities.

2 (Sc0tt-Cawiezell et al., 2009)

• I chose this article because it studied the implementation of eMARs at 5 different LTC facilities. It strongly focused on medication errors and how technology influenced them.

Study Designs

1 (Marasinghe, 2015)

• Theory: Information Theory

• Type: Qualitative Study

• Design: Systematic Review

38 articles were identified. 7 articles met inclusion criteria and were reviewed, 5 of which were RCT.

2 (Sc0tt-Cawiezell et al., 2009)

• Theory: Modernization Theory

• Type: Qualitative Study

• Design: Observational / Mixed Methods Approach

Study Methods

1 (Marasinghe, 2015)

• Methods:

MEDLINE, EMBASE, scopus, and Cochrane Library databases were search

LTC, medication safety, and CCDSS (Computerized clinical decision support systems) were keywords searched

38 articles were identified. 7 articles met inclusion criteria and were reviewed, 5 of which were RCT.

2 (Sc0tt-Cawiezell et al., 2009)

• Methods:

eMARs were implemented in 5 different LTC facilities. eMAR reports were reviewed for medication errors over the span of….

300 observations hours

16,000 medication doses

3,7000 residents

Study Findings

1 (Marasinghe, 2015)

• Findings:

CCDSS improved care in LTC in the following areas: quality of prescribing orders, detected adverse drug reactions, triggered warning messages, and reduced injury risk among older adults

2 (Sc0tt-Cawiezell et al., 2009)

• Findings:

The eMARs improved many aspects of care in LTC facilities, including communication. However, some of the framework instilled in the LTC medication administration process is so outdated, eMARs could not solve chronic structural issues. The technology opens the doors to improving medication safety in short term and long term.

2 (Sc0tt-Cawiezell et al., 2009)

Ethical Considerations

1 (Marasinghe, 2015)

• Because this study reviewed multiple different studies, ethical considerations can’t be properly assessed.

• No commercial or organizational funding was used in this study, but did not consider funding sources of reviewed articles.

2 (Sc0tt-Cawiezell et al., 2009)

• The 5 LTC facilities were willing to implement the large scale technology change. Medication safety teams consisted of invited staff members and other volunteers from each facility. Medication errors were observed through eMAR generated reports and not during actual administrations.

• The Agency for Healthcare Research and Quality funded this study.

Study Strengths

1 (Marasinghe, 2015)

• Strength: Large number of studies reviewed

• Quality: Highest – Systematic Review

• Credibility: No information or credentials on author Marasinghe, however, the article was posted in The BMJ Open, a peer reviewed journal.

2 (Sc0tt-Cawiezell et al., 2009)

• Strength: Large number of LTC facilities reviewed

• Quality: Low – no comparison group

• Credibility: All of the authors have a Ph. D. and/or RN. The article was published in The Joint Commission Journal on Quality and Patient Safety, which is also peer reviewed.

Inclusion Criteria

1 (Marasinghe, 2015)

• Studies needed to be either…

• Randomized Control Trial studies

• Cohort Studies

• Retro/prospective studes

• Needed to be LTC based

• Evaluated effects of CCDSS in terms of improving medication safety

• Written in English

• *Note – exclusion criteria did not consider funding sources

2 (Sc0tt-Cawiezell et al., 2009)

• Midwestern nursing homes in 3 states

• Interested and willing to make large scale technology change

• Typical LTC facilities

• Urban and Rural settings

• Various sizes (60-400) beds

• Various ownership structure

EBP Contribution

1 (Marasinghe, 2015)

• This article did not add any information or research, rather it just compiled multiple studies into one generalized report.

• No EBP contribution.

2 (Sc0tt-Cawiezell et al., 2009)

• This article provided useful information regarding the types and causes of medication errors in LTC facilities. By using the eMAR to properly track and record medication errors, we can view concrete data.

Relevant to Practice

1 (Marasinghe, 2015)

• Both articles are relevant to any LTC facility that is interested in implementing technology for medication administration and patient care.

• This information could be presented up to a administration level by staff nurses advocating

for patient and nurse safety.

2 (Sc0tt-Cawiezell et al., 2009)

Quality and Safety

1 (Marasinghe, 2015)

• These articles have information that can change practice and procedure while improving the

quality and safety of patient care on all levels.

• Nurses would have extra tools to determine medication schedules.

• Patient would have an extra level of protection from medication errors.

• Administration would have a greater way to monitor staff members and medication errors

and risks for errors.

2 (Sc0tt-Cawiezell et al., 2009)

Potential Barriers

1 (Marasinghe, 2015)

• Cost – Technology can be expensive, especially start up costs

• Training – LTC nurses typically use little technology and might not have much experience

2 (Sc0tt-Cawiezell et al., 2009)

Additional PICO Questions

1 (Marasinghe, 2015)

• “In long term care (LTC) facilities, how does the use of computerized clinical decision support

systems (CCDSS), compared to non computerized clinical decision support systems,

reduce nurse medication errors?”

• “In long term care (LTC) facilities, how does the use of computerized clinical decision support

systems (CCDSS), compared to non computerized clinical decision support systems,

improve patient care?”

2 (Sc0tt-Cawiezell et al., 2009)

Summary

• These studies did not exactly answer my PICO question, but they did give some general reassurance that the implementation of an eMAR did improve the medication administration process in LTC facilities.

• These studies also gave examples of how they reduced these errors and how they would reduced errors in the future.

• What the studies did not provide was quantitative data regarding the specific amount of errors that were reduced. This might be a difficult topic to study as many times medication errors either go unnoticed and/or unreported when using the traditional paper MAR.