Electronic prescribing

Safer intensive care prescribing: engaging users in the implementation of an electronic prescribing system

Medication errors are a global problem and can cause significant harm to patients [1, 2]. The most frequent type of avoidable medication errors are prescribing errors [3]. Electronic prescribing has been promoted as a solution to provide safer prescribing in hospitals.

The employment of electronic prescribing can improve patient safety by reducing medication errors. However, systems are frequently not adopted as the end users do not find them particularly effective. Insufficient engagement with the end users has resulted in systems which are not intuitive and do not meet their specific needs. Inappropriately designed systems have also resulted in the introduction of errors.

In situations such as intensive care, patients are in a critical condition and require constant close monitoring. Medical decisions are made continuously with patients being prescribed multiple medications, often in complicated combinations. This complexity of prescribing and high pressure environment increases the likelihood of errors and makes the intensive care unit (ICU) an ideal test-bed for considering the design and implementation of an electronic prescribing and administration system.

User-Centred Design “Successful technologies are those that are in harmony with the users’ needs. They must support relationships and activities that enrich the users’ experiences” [4]

Participatory design is an approach where the end users play a critical role in designing the system. Including end users in the design and development provides a greater opportunity for the users to influence the design and can give them a sense of ownership of the system [4]

An electronic system for prescribing and recording the administration of medicines in intensive care has been developed by a group from the School of Computing, University of Dundee, and clinicians from Ninewells Hospital and Medical School, Dundee.

A team was formed at the beginning of the project to facilitate the participatory process and to ensure interdisciplinary working. The team initially comprised a consultant in anaesthesia and intensive care, an intensive care fellow, the principal clinical pharmacist for critical care, the intensive care specialist liaison nurse, a professor of interactive systems design, a professor of assistive systems and healthcare computing, and a PhD computing student. Later, it evolved to include an intensive care staff nurse.

Interaction design process The development of the system was based on the lifecycle model for interaction design [5]. Figure 1 depicts the procedure followed to create the final product.

Figure 1 System development process

Ethnographic field studies were conducted at the beginning of the project, providing an initial understanding of the different users’ needs and the tasks that they required the system to carry out. Based on these observations and site visits to two UK hospitals that use electronic prescribing, the initial requirements were formed. A survey of prescribing errors in the ICU was also conducted to identify the types of errors and probe opportunities for reducing such errors.

The findings indicated that the interface of the electronic prescribing and administration system had to be intuitive, usable and designed to actively reduce prescribing errors. The design began as a set of paper prototypes which were evaluated by the team. These paper prototypes led to the development of an evolutionary prototype which was modified and refined, on the basis of feedback from the regular meetings with the team.

In addition to evaluating the evolving prototype with the interdisciplinary team, sessions were held with end users outwith the team. These sessions were also used to introduce the system to staff and to get their feedback. The feedback was presented to the interdisciplinary team and considered accordingly.

Prior to testing the electronic prescribing system in a live environment it was important to establish whether the electronic prescribing and administration system would be at least as good as the current paper system and not lead to the introduction of new errors. This led to a pilot study, conducted with 22 prescribers, to test the system under pressure and to compare prescribing errors between the paper and electronic systems.

Live trial

The electronic prescribing and administration system was subsequently introduced into the ICU, Ninewells Hospital, Dundee, and evaluated over a 5-month period (14th January – 5th June 2008).

Figure 2. The electronic prescribing system in use

To establish if there was any difference in the level of prescribing error when using the electronic system, comparisons of the paper and electronic medication charts were conducted. On completion of the trial, semi-structured interviews were held with a sample of clinicians to gain feedback about their experiences and attitudes toward the system.

The results from the study demonstrated that the electronic prescribing and administration system led to a significant increase in prescription compliance with nationally accepted standards and reduced prescribing errors significantly.

Responses from the interviews suggested that the electronic system produced a positive user experience and was favoured by the clinicians.

“I have been fortunate to use it quite a lot of times with patients” (Staff nurse)

“Very intuitive set of interfaces ... Simple to use” (Specialist registrar)

“You can see everything clearly” (Staff nurse)

“It was pretty well thought of, all the details were taken into consideration before, the only disadvantage was that it probably takes a little longer initially but once you get used to it this probably isn’t a factor… Over time I think it will probably be faster than paper, the most important thing is it’s much safer and it’s legible. You can’t understand everybody’s handwriting on a paper kardex, this is very very clear” (Specialist registrar)

“I really liked it. I thought the layout was good, easy to follow” (Staff nurse)

“I liked the screen and how it was laid out… It has a positive effect … there is no problems with illegibility of prescriptions” (Pharmacist)

Sustained engagement with end users ensured that they maintained enthusiasm throughout the design and development of the system. This proved to be a key factor in creating a usable electronic prescribing and administration system that minimises the risk of error. Adopting a participatory design approach and applying usability techniques has resulted in an improved system that is safer and preferred by the users.

The Dundee Electronic Prescribing Development Team:

Patricia Antoniewicz [i], Deborah A Corner [i], Stella Dailly [i], Prof Peter Gregor [ii], Dr Judith Joss [i], Fiona McIntyre [i], Dr. Shaun McLeod [i], Prof Ian W Ricketts [ii], Dr Alfred J Shearer [i], Kathryn Went [ii]

i. Ninewells Teaching Hospital & Medical School Dundee, NHS Tayside, Dundee, Scotland
ii. School of Computing, University of Dundee, Dundee, Scotland

References

1. Department of Health. Building a safer NHS for patients: Improving Medication Safety. The Stationery Office, London, 2004.
2. Institute of Medicine. To err is human: Building a safer health system. National Academic Press, Washington DC, 2000.
3. Wheeler SJ, Wheeler DW. Medication errors in anaesthesia. Anaesthesia, 60 (2005), 257-273.
4. Shneiderman B, Plaisant C. Designing the user interface: Strategies for effective human-computer interaction. Addison Wesley, New York, 2005.
5. Preece J, Rogers Y, Sharp H. Interaction Design: Beyond Human-Computer Interaction. Wiley, New York, 2002.