Improving Patient Safety and Clinician Cognitive Support Through eMAR Redesign

The acute care medication prescribing process involves careful coordination between physicians, nurses, and pharmacists. Health information technology (IT) applications can help facilitate this process. Health IT applications that are designed and used appropriately support the medication process, resulting in fewer medication errors, but poorly designed and implemented IT can create errors. Physicians order medications using computerized provider order entry (CPOE), while nurses and pharmacists manage medication administration using electronic medication administration records (eMARs) and barcode medication administration (BCMA). In particular, some eMARs do not support the cognitive needs of physicians, nurses, and pharmacists, resulting in poor communication, suboptimal information flow, and a lack of situational awareness for patients’ medications.

This study will examine eMAR usability and safety hazards with a focus on communication and information flow among eMARs and other health IT applications. The objective is to reduce the patient safety hazards associated with eMARs by (1) understanding usability and safety gaps, and (2) creating design and development documents, wireframes, and prototypes to serve as the foundation for future eMARs to eliminate these gaps. Researchers will take a systems approach by examining interdisciplinary users to ensure needs are being met across the medication process.

The specific aims of the research are as follows:

• Analyze a diverse set of medication-related patient safety event reports to identify specific problematic aspects of CPOE-eMAR-BCMA activities that contribute to medication errors. 
• Conduct multi-method usability evaluations of current eMAR-related processes. 
• Iteratively design, develop, test, and disseminate eMAR wireframes and prototypes. 

While medication administration in high-volume inpatient units is already complex and cognitively taxing, it has become even more complex during the COVID-19 pandemic as nurses are managing higher-acuity patients, complex medication treatments, and the need for deliberate planning to limit exposure to infected patients while also delivering robust care. Accessing the patients’ infectious disease status at the time of planning medication administration, and clearly understanding patients’ medication needs, are critical for nurses to be able to strategically prioritize patient care activities. However, the design of eMARs, as well as other health IT systems, do not currently support these complex tasks of information gathering, organization, and planning, making it difficult for nurses to obtain the ‘big picture’ or situation awareness across all patients under their care. These shortcomings of the eMAR leave nurses, patients, and other healthcare providers at risk of exposure to COVID-19 and introduce other patient safety risks, such as medication errors. To address this need, a supplemental grant to the initial research has funded the researchers to develop a human factors-informed medication administration workflow risk assessment tool to improve safety practices. Combined with developed test cases, the tool will allow healthcare facilities and electronic health record vendors to rigorously assess their medication administration workflow for system usability and safety.

This research will improve understanding of the role of health IT during medication administration with a focus on information flow, design, and safety. The development of a risk assessment tool and new prototype eMAR will allow healthcare systems and technology vendors to improve medication administration workflow, of even more importance during COVID-19 with its inherent increased risks to patient safety.