HIMSS Analytics survey: Moving medications through multiple systems trip up medication safety efforts

More than 50 percent of the respondents who participated in the 2017 Medication Management and Safety Study stated that the greatest gap in medication management occurs when transitioning from one place to another and at the patient bedside.
04:22 PM

Healthcare organizations across the country now rely on a variety of technologies to prevent medication errors, yet patients remain vulnerable during care transitions, according to a recent survey of 153 physicians, nurses and pharmacists conducted by HIMSS Analytics.

“Even though organizations have implemented a variety of information and medication technologies, many healthcare providers continue to experience significant challenges with medication management – all the way from the procurement of drugs through to the administration,” said Patricia Wise, RN, vice president of healthcare information systems at HIMSS.

More than 50 percent of the respondents who participated in the 2017 Medication Management and Safety Study stated that the greatest gap in medication management occurs when transitioning from one place to another and at the patient bedside. Care transitions are especially vexing because “most patients don’t arrive or depart with one source of truth,” according to Wise.

Joyce Sensmeier, RN, vice president of informatics at HIMSS, agrees. “That time when one nurse is turning over patients to another nurse is critical because, as the receiving nurse, you have to make sure you're getting all the right information about your patients. The system should bring the most current information forward to the clinician who is taking over,” Sensmeier said. “Nurses rely on the technology to get it right but often disparate systems result in nurses running, hunting and gathering. So, they are running around, getting medications, coming back to the patient’s room. They can easily be interrupted three times and that could affect medication administration.”

Indeed, there are numerous glitches that could potentially introduce error into the medication administration process. Consider the following: When a patient at an Oregon hospital needed an intravenous anti-seizure medication called fosphenytoin, clinicians accidentally administered rocuronium, which caused the patient to stop breathing and go into cardiac arrest, according to a report published in The Bulletin. While it was obvious that a mistake was made, it was not immediately clear as to what went wrong during the medication process.

“There are a number of steps in there,” said the hospital’s chief clinical officer, “We’ve never had anything like this happen here. We are in the process of that analysis right now. Before we say exactly what happened, we’re going to make sure we’re accurate about [it]. We do know there was a medication error. We acknowledge that. It’s our mistake.”1

Healthcare organizations are leveraging technology to help eliminate errors.  More than 80 percent of survey respondents indicated that their organizations have implemented a single EHR – a solution that could potentially help to provide a “source of truth” during care transitions. And, more than 70 percent of the clinicians surveyed acknowledged the value of moving toward a single vendor for other medication management technologies as well.

Indeed, as various technologies become more integrated, patient care could potentially become safer. “More hospitals are integrating their medication management technologies with the EHR and that is making it possible to reduce the risk of medication errors and fatalities, while making it simpler and more streamlined for nursing,” Sensmeier said.

She further explained that integration between the smart infusion pump and the EHR, for example, could eliminate medication errors as nurses will no longer have to calculate the intravenous dosage and drip rate. “Ideally, such integration should significantly decrease errors, but there are a lot of moving parts associated with connecting the pump to the EHR, as well as to the patient,” she added.  

While this integrated technology will never completely stop clinicians – who are human – from making errors, it can help to create the safeguards that prevent errors from reaching patients. As a result, organizations can not only protect patients but also cut the costs associated with medication errors, which were estimated to run in excess of $2 million annually by respondents who work at hospitals with more than 250 beds.

“It all goes back to the importance of improved systems,” said Erica Mobley, director of operations at the Leapfrog Group, a national non-profit organization dedicated to advancing the quality and safety of American healthcare. “We all recognize that hospitals are staffed by people, and people make mistakes. Unfortunately, when people make mistakes in healthcare, lives are at risk. No one wants to harm patients, so we need to have the systems in place so that when people do make mistakes, the mistakes do not reach the patients.”


1. Bannon, R. Error at St. Charles Bend results in patient’s death. The Bulletin. http://www.bendbulletin.com/localstate/2654383-151/error-at-st-charles-b...

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