ADVERTISEMENT
Workarounds During the Transcription of Medication Orders in the Long-Term Care Setting
The concept of medication appropriateness is receiving increased attention, and debate has arisen with regard to the effectiveness of using explicit criteria to evaluate quality of prescribing methods. Verification of the correct indication for a medication is an important step in the medication reconciliation process, especially for those transitioning to the long-term care setting. However, all too often, information necessary to determine the appropriate prescribing indication for each medication may not be available at the time of transition of care, presenting the receiving healthcare professional (HCP) with a difficult decision: spend limited time/personnel resources to attempt to verify the indication, or work around the block by making an assumption of indication. Such healthcare workarounds, in which HCPs create a mechanism to circumvent a block in workflow, can compromise data integrity and place patients at risk by omitting steps designed to provide verification or safety checks. This review highlights the often-overlooked practice of workarounds and their contribution to missing or inaccurate indication information, which can compromise patient safety.
Key words: long-term care, patient safety, medication errors, documentation, workflow, medical order entry systems.
Abstract: The concept of medication appropriateness is receiving increased attention, and debate has arisen with regard to the effectiveness of using explicit criteria to evaluate quality of prescribing methods. Verification of the correct indication for a medication is an important step in the medication reconciliation process, especially for those transitioning to the long-term care setting. However, all too often, information necessary to determine the appropriate prescribing indication for each medication may not be available at the time of transition of care, presenting the receiving healthcare professional (HCP) with a difficult decision: spend limited time/personnel resources to attempt to verify the indication, or work around the block by making an assumption of indication. Such healthcare workarounds, in which HCPs create a mechanism to circumvent a block in workflow, can compromise data integrity and place patients at risk by omitting steps designed to provide verification or safety checks. This review highlights the often-overlooked practice of workarounds and their contribution to missing or inaccurate indication information, which can compromise patient safety.
Key words: Long-term care, patient safety, medication errors, documentation, workflow, medical order entry systems.
Citation: Annals of Long-Term Care: Clinical Care and Aging. 2015;23(7):33-37.
______________________________________________________________________________________________________________________________
Much attention is being paid to the concept of medication appropriateness, and there have been several studies in which medication appropriateness has been evaluated on the basis of explicit criteria. Attempts to show a favorable impact on patient outcomes through the reduction of medication use based on these criteria have had mixed results.1–4 Therefore, the focus has more recently shifted from identifying “inappropriate medications” to identifying “inappropriate use” of medications. Evaluation of appropriate medication use requires a fundamental understanding of a medication’s intended therapeutic outcome for a given patient. The use of a medication without evidence of the indication for use constitutes unnecessary medication use, per long-term care (LTC) regulations.5 When the medication and indication are not aligned correctly, the potential exists for incomplete or inaccurate information within the patient’s chart to continue to be passed down in a continuum of care. Therefore, verification of the correct indication for a medication is an important step in the medication reconciliation process, especially for those transitioning to the LTC setting.
For this reason, missing or inaccurate indication or diagnostic data is an important problem that must be addressed. The perpetuation of incomplete or inaccurate records is common: lack of appropriate indication has been described as one of the most prevalent medication-related problems associated with LTC medical records review, with some studies reporting most facility residents taking at least one medication without a valid indication for use.6,7 This is especially described in reviews of psychoactive medication use in this setting.8,9
Often, the information necessary to determine the appropriate prescribing indication for each medication may not be available at the time of transition of care. This presents the receiving healthcare professional (HCP) with a difficult decision: spend limited time/personnel resources to attempt to verify the indication, or work around the block by making an assumption of indication. The latter approach is an example of a healthcare workaround, in which an HCP experiences a workflow block and, instead of completing the process as intended, creates a mechanism to avoid the block.10 In simple terms, workarounds are shortcuts.11 A growing body of literature has begun evaluating this concept of healthcare workarounds, which are often attributed to clinicians responding to the complexities of care within a system that increasingly demands standardization.12 Some may argue that the practice of workarounds leads to improved efficiency through the identification of ways of completing tasks more simply or more quickly. However, by circumventing steps designed to provide verification or safety mechanisms, they have the potential to compromise data integrity and place patients at risk.13
All healthcare organizations devise work processes aimed at enhancing patient safety, but for every process designed and implemented, there is always a question of how well that process is followed and whether a lack of adherence to that process compromises outcomes. The use of workarounds across the health system perpetuates inaccurate or incomplete data because they circumvent medication history and reconciliation processes that ostensibly exist to prevent adverse medication outcomes. In particular, processes related to medication ordering, transcribing, and reconciliation have attracted attention, because medication errors are common and often avoidable.14 In this review, we hope to shed light on an often overlooked practice contributing to missing or incorrect medication information, which can hinder the assessment of medication appropriateness in the LTC setting.
Workarounds During the Transcription of Medication Orders
The literature suggests that workarounds are more common in processes that involve documentation and technology. A study within an LTC facility showed that technology employed in the medication administration process contributed to the increased use of workarounds.15 More specifically, the increased use of electronic health records (EHR) and bar code medication administration within health systems appears to be associated with increased use of workarounds, greatly increasing the potential for medication errors.16
Although there are multiple steps in medication ordering and transcribing, most previous studies of computerized order entry behaviors focused on the prescriber,17 the individual who most understands the intent of the medication. By contrast, in an LTC setting, medication orders are typically transcribed by an agent of the prescriber, often the charge nurse or other member of the facility staff, who are often unfamiliar with the patient. During transcription, indications for medications should be verified in the clinical record. Whether an LTC facility is using an EHR or a paper charting system, LTC regulations require that each medication have an indication. Both EHR and paper-based systems include mechanisms for safeguarding against the incomplete entry of patient data by requiring that indications be entered in order to complete processing of paperwork. For those facilities using EHR, some systems include a data field requiring that an indication be added to each order. Facilities with paper-based systems will often employ a mechanism by which the indication is added to the Medication Administration Record (MAR).
But inherent in these safeguards is the potential for a potentially dangerous workaround. When such documentation in an individual’s medication record is incomplete upon admission to an LTC facility, rather than verifying the indications with the prescriber, the person entering the information may omit this step by assuming or guessing the reason for medication use and documenting an unverified or inappropriate indication in order to complete the required field and remain in compliance with regulations.
This workaround could seem like an example of facility staff utilizing problem-solving skills for expedient task completion; however, in reality, the omission of indication information can lead to confusion and misinformation. In the outpatient setting, most states do not require that a valid prescription include documentation of the indication for medication use. From the standpoint of facility records review and patient safety, however, the absence of this information leaves the facility staff, the consultant pharmacists, and the prescriber ill-equipped to recommend or implement the adjustment or discontinuation of medications for residents. In this context, a well-intended intervention to alter drug therapy to avoid an adverse event may itself result in an adverse outcome if the choice is based on inaccurate or incomplete data. Likewise, fear of such an outcome can, in turn, result in a reluctance to adjust drug therapy in the future. Additionally, the risk of patient harm exists,14,16,18–21 especially when patient safety systems are worked around.22,23,24
Although studies have focused on the concept of workarounds in several different settings, there is scant literature that specifically addresses the impact of failure to verify medication indication at the order transcribing or order entry stage in the LTC setting. A pilot project within one LTC facility utilizing EHR reported the prevalence of medication-indication mismatch to be 33%, with 24% of orders having an inappropriate indication and 9% of orders having no indication documented.25 The top five medications with inappropriate indications were potassium chloride, acetaminophen, aspirin, multivitamins, and hydrocodone/acetaminophen. Examples of inappropriate indications for a given medication included: “allergic rhinitis” for risperidone; “arthropathy” for omeprazole; “fixation, neck of femur” for docusate; “macular degeneration” for tizanidine; “peripheral neuropathy” for isosorbide dinitrate; and “MRSA” for acidophilus, to cite a few. The findings of this study suggest the intended medication–indication match may not be clear to the transcribing HCP, who is one or more steps removed from the prescriber. Moreover, these results illustrate the frequency with which this step is bypassed in practice, in order to complete the order entry task.
Identifying the Causes of Workarounds
Although the prevalence of medication–indication mismatch in LTC facility records has been identified, this phenomenon has not been historically described as being the result of workarounds, per se. Several hypotheses exist as to why medication-indication workarounds occur. The root cause of workarounds may be a lack of understanding of a procedure’s purpose: if HCPs fail to appreciate the importance of a specific step, they may choose to simply forego it. HCPs may perceive verification of the indication for each medication as time-consuming or unnecessary, and the documentation of this information as a minor point of regulatory detail.
Lack of drug knowledge is another hypothesis for why medication indication workarounds occur. This is likely too simplistic an explanation for the results observed in the pilot project described above, however. Although it is possible that the individuals transcribing the medication orders were unfamiliar with the products and simply guessed the indications, the prospect that this type of occurrence could account for a medication-indication mismatch rate of 33% would be startling in any healthcare setting. In addition, one might question whether the drug knowledge of the individual transcribing the order is the most germane point. Awareness of what conditions a drug can be used to treat is different than understanding the intended purpose of that drug within a specific patient’s treatment plan; this becomes an important distinction when determining medication appropriateness. It is likely that other health system variables contributed to the observed results.
Incomplete documentation from multiple providers may also be to blame. Multiple providers participate in resident care within an LTC facility, and because of the open-vendor nature of this setting, style and quality of medical documentation can vary with each provider. In addition, patients’ medical histories may not be updated to keep pace with the frequency of medication changes. Moreover, the primary medical record documentation for patients in an LTC facility, which is completed by the attending physician, is only required monthly for the first 3 months after admission, then bimonthly thereafter.5 Whereas some patients enter the LTC facility with a relatively stable medication regimen, it is common for many new residents to encounter changes to their medications that occur between these points of official physician documentation. Additionally, many facilities have protocols in place for consultations with specialty services in cases of complicated disease processes (eg, neuropsychiatric symptoms of dementia) after admission to an LTC facility. Ideally, notes from all specialists and providers would be maintained in the record, but the onus is on the facility staff to obtain these documents from outside providers. Indeed, the number of prescribing physicians has been reported to be an independent risk factor for adverse drug events in older populations.26 When the medication regimen contains orders from multiple providers, lack of even just a single provider’s note can result in medications without documented indication, increasing the patient’s risk for an adverse event.
A lack of familiarity with the patient may contribute to the occurrence of workarounds when entering medication information. Often, a provider receiving an individual being admitted to an LTC facility does not have a previous relationship with that patient. In such cases, the provider must rely on the accuracy of documentation from the previous provider, and may sign or authenticate a medical history and physical or discharge document brought over from the previous care setting in lieu of writing a new one. Therefore, the diagnosis list that supports a drug regimen may be limited to those disease states and problems addressed in the previous environment.
Finally, medication-indication workarounds may be the result of cursory medication reconciliation (MR) practices. MR is a systematic process designed to enhance patient safety by validating a patient’s current medication regimen at every point of care. As such, it is an important step toward improving quality and safety. The industry has struggled to develop and implement an efficient and effective process to accomplish this task. The result has been the inconsistent adoption of a patchwork of processes across various facilities or health systems. The basic concept of MR involves the comparison of drug list to drug list—usually home medications to institutional orders to discharge orders27—and often does not include an assessment of medication–indication match.28 Over-the-counter products are often not included in MR processes.29 In addition, even if performed accurately, a simple list-to-list comparison does not provide an explanation of intended purpose for each drug. Therefore, when receiving transfer orders that have undergone MR, it is easy for a provider to assume, incorrectly, that all medications on the list have a purpose.
The prescriber is really the only source that can be used to verify an order’s intent when the medication–indication match is unclear, but there are many barriers to this verification. For one, the prescriber is usually remote to the LTC site of care. For another, Nursing Practice Act regulations require timely implementation of medication orders, which usually means that the medication is on hand before the hour of the first scheduled dose. Therefore, the extra step of verifying the medication indication could be perceived as a delay of care. Finally, an HCP may be reluctant to disturb busy professionals with clarification requests.
When assessing the impact of workarounds, it is important to consider the perspectives of each HCP whose practice is affected by them. At the level of the healthcare worker, the need for workarounds can be disheartening, can make workers feel powerless,30 and can diminish provider satisfaction.22,31 Interprofessional relationships can be harmed when one discipline views the workaround of another discipline as ultimately making their job more difficult.30 Workarounds may then be perpetuated when trainers instruct their trainees to perform them.30 Lastly, workarounds lead to missed opportunities to fix the system if those involved in decisions to adjust or adopt new technology are led to assume the systems in place are working.30
Finding a Solution to the Problem of Workarounds
With all these potential reasons for workarounds, the question then becomes: what can be done? Unfortunately, few evidence-based solutions exist.22 Administrators and key clinical personnel must communicate and work together to find solutions that will see success in today’s healthcare environment.30,32 The first step for those involved in the process could be the implementation of an easy problem-reporting system and a “no blame” culture regarding medication errors.30 With regard to transitions of care, incomplete data following the patient to the LTC setting makes the process of MR difficult, time consuming, and cumbersome. The utilization of a “core record” has been advocated for by a number of different professional organizations.33 Facilities and medical directors can also work with local referral sources to ensure all documentation needed for a smooth and safe transition to the LTC facility, including an assessment of a medication’s indication and continued necessity, accompanies the patient upon admission. Within the LTC environment, the impact of reimbursement on the number and education level of licensed staff has no doubt had an impact on the time and ability to do MR accurately and completely. Staffing and time constraints might be mitigated by a dedicated intake nurse whose sole responsibility is to ensure a smooth transition into the facility—including, but not limited to, accurate and complete MR. However, this intervention may come with an additional cost to the facility.
Although position statements, consensus statements, and white papers addressing transitions of care and information technology are now increasingly common from major players in national and global health,34–36 the concept of workarounds is typically a bullet point within these larger documents. Most commonly, these documents point out the potential issue of workarounds and the need to monitor for them but do not make them the focus of their research or commentary.
Conclusion
Workarounds are symptoms of larger problems. The task of determining medication appropriateness, specifically “appropriate use” (and therefore having confidence in interventions to alter therapy), is hampered when the supporting indication is not reliable. When regulations and, more importantly, medication safety and good practice, require each medication’s indication to be documented, but the indication for each medication is not clear, a workflow block forces a choice: verify the indication or work around the block. Workarounds in such cases clearly occur. It remains unclear whether the cause is unnecessary medication, poor history documentation, reticence to seek clarification, poor drug knowledge, or a combination of these. Instead, there appears to be a stream of inaccurate or incomplete data perpetuated across transitions in care that oversight mechanisms such as MR, well intended though they are, are not completely able to catch and resolve. These data have the potential to leave members of the healthcare team ill equipped to evaluate medication appropriateness, and render all vulnerable to perpetuating an inappropriate medication and possibly a preventable adverse drug event. Given the multifactorial nature of the problem, having all stakeholders at the table when devising a solution will be key.
References
1. Hanlon JT, Fillenbaum GG, Kuchibhatla M, et al. Impact of inappropriate drug use on mortality and functional status in representative community dwelling elders. Med Care. 2002;40(2):166-176.
2. Hamilton H, Gallagher P, Ryan C, Byrne S, O’Mahony D. Potentially inappropriate medications defined by STOPP criteria and the risk of adverse drug events in older hospitalized patients. Arch Intern Med. 2011;171(11):1013-1019.
3. Page RL II, Ruscin JM. The risk of adverse drug events and hospital-related morbidity and mortality among older adults with potentially inappropriate medication use. Am J Geriatr Pharmacother. 2006;4(4):297-305.
4. Kanaan AO, Donovan JL, Duchin NP, et al. Adverse drug events after hospital discharge in older adults: types, severity, and involvement of Beers Criteria Medications. J Am Geriatr Soc. 2013;61(11):1894-1899.
5. Centers for Medicare and Medicaid Services. State Operations Manual: Appendix PP – Guidance to Surveyors for Long Term Care Facilities; Rev. 107. CMS website. www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf. Published April 4, 2014; accessed May 18, 2015.
6. Williams BR, Nichol MB, Lowe B, Yoon PS, McCombs JS, Margolies J. Medication use in residential care facilities for the elderly. Ann Pharmacother. 1999;33(2):149-155.
7. Parsons C, Lapane K, Kerse N, Hughes C. Prescribing for older people in nursing homes: a review of the key issues. Int J Older People Nurs. 2011;6(1):45-54.
8. Stevenson DG, Decker SL, Dwyer LL, et al. Antipsychotic and benzodiazepine use among nursing home residents: findings from the 2004 National Nursing Home Survey. Am J Geriatr Psychiatry. 2010;18(12):1078-1092.
9. Briesacher BA, Limcangco MR, Simoni-Wastila L, et al. The quality of antipsychotic drug prescribing in nursing homes. Arch Intern Med. 2005;165(11):1280-1285.
10. Halbesleben JR, Rathert C, Bennett SF. Measuring nursing workarounds: tests of the reliability and validity of a tool. J Nurs Adm. 2013;41(1):50-55.
11. Halbesleben JR, Wakefield DS, Wakefield BJ. Work-arounds in health care settings: Literature review and research agenda. Health Care Manage Rev. 2008;33(1):2-12.
12. Debono DS, Greenfield D, Travaglia JF, et al. Nurses’ workarounds in acute healthcare settings: a scoping review. BMC Health Serv Res. 2013;13:175.
13. Debono D, Greenfield D, Black D, Braithwaite J. Workarounds: straddling or widening gaps in the safe delivery of healthcare? www.download.bham.ac.uk/hsmc/deborah-debono.pdf. Paper presented at The Seventh Biennial Conference in Organisational Behavior in Health Care; April 11-14, 2010; Birmingham, United Kingdom.
14. Halbesleben JR, Savage GT, Wakefield DS, Wakefield BJ. Rework and workarounds in nurse medication administration process: implications for work processes and patient safety. Health Care Manage Rev. 2010;35(2):124-133.
15. Vogelsmeier AA, Halbesleben JR, Scott-Cawiezell JR. Technology Implementation and Workarounds in the Nursing Home. J Am Med Inform Assoc. 2008;15(1):114-119.
16. Koppel R, Wetterneck T, Telles JL, Karsh BT. Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. J Am Med Inform Assoc. 2008;15(4):408-423.
17. Holden RJ. What stands in the way of technology mediated patient safety improvements?: A study of facilitators and barriers to physicians’ use of electronic health records. J Patient Saf. 2011;7(4):193-203.
18. Patterson ES, Cook RI, Render ML. Improving patient safety by identifying side effects from introducing bar coding in medication administration. J Am Med Inform Assoc. 2002;9(5):540-553.
19. Patterson ES, Rogers ML, Chapman RJ, Render ML. Compliance with intended use of Bar Code Medication Administration in acute and long-term care: an observational study. Hum Factors. 2006;48(1):15-22.
20. de Leval MR, Carthey J, Wright DJ, Farewell VT, Reason JT. Human factors and cardiac surgery: a multicenter study. J Thorac Cardiovasc Surg. 2000;119(4 Pt 1):661-672.
21. Spear SJ, Schmidhofer M. Ambiguity and workarounds as contributors to medical error. Ann Intern Med. 2005;142(8):627-630.
22. Halbesleben JR, Rathert C. The role of continuous quality improvement and psychological safety in predicting workarounds. Health Care Manage Rev. 2008;33(2):134-144.
23. Pape T. Workaround error. Agency for Healthcare Research and Quality (AHRQ) website. Published February 2006; accessed May 18, 2015.
24. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161-167.
25. Sleeper RB, Pham-Smith L. Workarounds in the medication reconciliation and order entry process in a long term care facility. Paper presented at the American Society of Consultant Pharmacists (ASCP) Annual Meeting, November 21, 2013; Seattle, WA.
26. Green JL, Hawley JN, Rask KJ. Is the number of prescribing physicians an independent risk factor for adverse drug events in an elderly outpatient population? Am J Geriatr Pharmacother. 2007;5(1):31-39.
27. Greenwald JL, Halasyamani L, Greene J, et al. Making inpatient medication reconciliation patient centered, clinically relevant and implementable: A consensus statement on key principles and necessary first steps. J Hosp Med. 2010;5(8):477-485.
28. Kwan JL, Lo L, Sampson M, Shojania KG. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):397-403.
29. Harris CM, Sridharan A, Landis R, Howell E, Wright S. What happens to the medication regimens of older adults during and after an acute hospitalization? J Patient Saf. 2013;9(3):150-153.
30. Johnson JK, Miller SH, Horowitz SD. Systems-Based Practice: Improving the Safety and Quality of Patient Care by Recognizing and Improving the Systems in Which We Work. In: Henriksen K, Battles JB, Keyes MA, et al, ed. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 2: Culture and Redesign). Rockville, MD: Agency for Healthcare Research and Quality; 2008.
31. Beaudoin LE, Edgar L. Hassles: their importance to nurses’ quality of work life. Nurs Econ. 2003;21(3):106-113.
32. Uhlig PN, Brown J, Nason AK, Camelio A, Kendall E. John M. Eisenberg Patient Safety Awards. System innovation: Concord Hospital. Jt Comm J Qual Improv. 2002;28(12):666-672.
33. Snow V, Beck D, Budnitz T, et al. Transitions of Care Consensus Policy Statement American College of Physicians – Society of General Internal Medicine – Society of Hospital Medicine – American Geriatrics Society – American College of Emergency Physicians – Society of Academic Emergency Medicine. J Gen Intern Med. 2009;24(8):971-976.
34. The Governance Institute. Leadership in healthcare organizations: A guide to joint commission leadership standards. The Joint Commission website. www.jointcommission.org/assets/1/18/wp_leadership_standards.pdf. Published in 2009; accessed May 19, 2015.
35. Patient Safety: Action on Patient Safety – High 5s. World Health Organization Website. www.who.int/patientsafety/implementation/solutions/high5s/en/. Accessed May 19, 2015.
36. Patient Safety: WHO Collaborating Centre for Patient Safety Solutions. Patient safety solutions newsletter. 2007;1(2):1-4.
