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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 Pharm 2002;59:731-3).

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.
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