Remote order entry: Innovative practice
to reduce distractions and offer 24-hour pharmacy service
From the April 17, 2002 issue
PROBLEM: Could these two errors happen in your hospital?
A new patient did not receive his antibiotic for over 24 hours.
The order for cefazolin 1 g IV q8h was overlooked during order
entry of a large set of new orders because the pharmacist was
repeatedly interrupted during the process. Likewise, with several
new admissions, the nurses failed to detect that the computer-generated
medication administration record did not list the medication.
The error was discovered later during a chart check. In another
hospital, an infant received one oral dose of 6,264 mg of calcium
glubionate instead of 400 mg. The product wasn't available on
the unit and was prescribed at night when the pharmacy was closed.
Through a series of errors, the elemental calcium concentration
of 115 mg/5 mL was mistaken as the calcium glubionate concentration
(which is 1800 mg/5 mL) and the patient received 17.4 mL of
the syrup instead of the correct volume of 1.1 mL. The infant's
serum calcium level rose, but he sustained no harm.
As in most pharmacies, distractions during the order entry process
contributed largely to the first error. Interruptions from phone
calls, staff questions, walk-in business, and requests to check
technicians' work are quite common and likely at the root of
many pharmacy errors. Among several causes of the second error
is another common problem - lack of pharmacy services at night.
Data from the 2000 ISMP Medication Safety Self Assessment
showed that only 35% of responding hospitals offered 24-hour
pharmacy services. So, frequently, a pharmacist is not available
to review medication orders before administration.
SAFE PRACTICE RECOMMENDATION: While the causes of these
two errors are quite different (frequent interruptions during
order entry and lack of nighttime pharmacy service), both originated
in the pharmacy. But to improve the dispensing process, hospitals
face daunting obstacles such as staff shortages, financial constraints,
space limitations, workflow issues, and insufficient levels
of nighttime activity to support 24-hour pharmacy services.
Nevertheless, in the most recent edition of the American
Journal of Health-System Pharmacy, Cronk describes an innovative
solution - remote order entry - that can be used in multihospital
systems to prevent errors related to both problems cited above
(Cronk J. Digital scanning and consolidated entry of medication
orders in a multihospital health system. Am J Health-Syst
According to Cronk, the pharmacy order entry process for eight
hospitals within his health system is centralized in a separate
area at one of the hospitals. The pharmacists who work in the
remote pharmacy have access to each hospital's pharmacy computer
system and other electronic data (lab, radiology, etc.). The
orders are sent to the remote pharmacy via digital scanning
or fax. While the remote pharmacy is totally isolated from other
pharmacy functions, each pharmacist has a headset for easy contact
with other pharmacists. After order entry, the drug is accessible
in automated dispensing equipment or dispensed from the appropriate
pharmacy. Now Cronk plans to staff the remote pharmacy at night
to cover all eight hospitals (four do not offer 24-hour pharmacy
services). Minimal distractions, improved staffing patterns,
high satisfaction levels, expanded clinical pharmacy activities,
and reduced medication errors have been achieved. While it's
still too early to tell if remote order entry will be successful
in other hospital systems, or even through agreements between
unrelated facilities (or via telepharmacy as described by Keeys
et al. in the same AJHP issue), it's clear that this
innovative practice holds promise.