A New Era: The Pros and Cons of ePMA Systems in Practice in the NHS

The last 5 years have seen a rapid rise in the use of electronic Prescribing and Medicines Administration (ePMA) systems across NHS trusts. But how safe are they? Priscilla Lynch reports.

Electronic Prescribing and Medicines Administration (ePMA) machines continue to be rolled out across hospital trusts as a key part of the NHS’s ambitious plan to eliminate paper prescribing in hospitals and introduce digital prescribing across the entire NHS by 2024.

Figures provided by NHSX, the organisation tasked with driving forward digital transformation in healthcare, show that around 50% of trusts are currently using ePMA systems, with a further 25-30% funded for go-live dates over the next 12-18 months, following some roll-out delays due to the COVID-19 pandemic.

However, a recent national investigation report by the Health Safety Investigation Branch (HSIB) has raised concern that they are not as safe as commonly believed and have capacity to cause technology-related medication dosing errors, particularly in paediatric services.

So What are the Pros and Cons of ePMAs and is Enough Being Done To Ensure Patient Safety?

There are an estimated 237 million medication errors per year in the NHS in England, with 66 million of these potentially being clinically significant. These errors are estimated to cost the NHS at least £98 million and contributing to the loss of more than 1700 lives annually, according to a study published in BMJ Quality & Safety .

NHS England maintains that increased uptake of ePMA systems by trusts would correspond with a 30% reduction in medication errors, compared to traditional methods, and a similar reduction in patient adverse drug events.

They have many obvious benefits – ePMA systems can enhance patient safety by ensuring that critical information is provided in a timely way, and automate processes to be more efficient while reducing the risk of error. Medication reviews can be easily undertaken, and prescriptions automatically linked to discharge letters.

The use of ePMA systems has been shown to save time and money by reducing unnecessary bureaucracy, freeing up clinician time; instead of relying on sometimes unintelligible handwritten notes and paper medicine charts, health staff can quickly access crucial information across a range of sites and technical devices.

"Indeed, they can facilitate improved patient safety by, for example, alerting the prescriber of a drug allergy or interaction. They also allow organisations to understand prescribing habits and ensure good medicines management," a spokesperson for NHS Digital told Medscape UK.

Benefit - Mass Recording of Data

An average sized hospital will create around 1750 new prescriptions daily resulting in 8000 medicine administrations daily, noted NHS Digital.

Mass recording of data is thus another key benefit of ePMA systems, to enable the monitoring of individual hospital and wider trust prescription trends, and check against patient outcomes. The data can also be linked to other datasets to provide new insights and support medical research, enabling evidence-based policy decisions.

Since December 2020, NHS Digital has established a daily collection of data relating to medicines prescribed and administered to patients from secondary care NHS trusts with ePMA systems in England. In April 2021, it announced that this data was being made available to support COVID-19 research, and that it was expanding the number of ePMA systems that would provide this information (there are a number of different ePMA providers operating in the UK market).

Speaking at the time, Ann Slee, Associate CCIO (Medicines) at NHSX, said: '"This is a huge step forward and forms the basis for the longer-term national collection of ePMA data that will support numerous medication safety and other overprescribing initiatives.

"It will help us to further develop the right standards to underpin hospital prescribing and deepen our understanding of and approach to managing challenges such as antimicrobial resistance."

Safety Issues

While one of the main reasons for implementing ePMA is reducing medication errors, the findings of a recent systematic review and meta-analysis conducted by Gates et al (2021) concluded that their impact is actually variable.

"Despite the wide-scale adoption of EMS [electronic medication systems] in hospitals around the world, the quality of evidence about their effectiveness in medication error and associated harm reduction is variable. Some confidence can be placed in the ability of systems to reduce prescribing error rates. However, much is still unknown about mechanisms which may be most effective in improving medication safety and design features which facilitate new error risks," the study said.

And while research has shown that ePMA systems reduce errors associated with legibility and transcription, they can also create new types of errors rather than eliminate error burden, as there is a lack of standardisation in their use in the UK.

NHS Digital has acknowledged that "it must be recognised that failure, design flaws or incorrect use of such systems have the potential to cause harm to those patients that the system is intended to benefit".

Tenfold Errors

Prescribing errors are the most frequent type of medication error in paediatric inpatient healthcare settings. Prescribing for children is complex, because prescriptions must be individually tailored based on factors such as weight, age, gestation and body surface area. One of the biggest concerns with ePMA systems is the potential for 'tenfold' errors, especially in paediatric services.

As previously reported, the HSIB recently conducted a national investigation into weight-based medication errors in children, triggered by a case of unintentional tenfold overdose in a 4-year-old child.

An anticoagulant for the reference case child was prescribed by a junior doctor using the hospital’s ePMA system. Although the clinician had correctly interpreted the dose from the guiding formularies, the prescribing pathway led to the administration of the tenfold overdose on five separate occasions before it was identified.

As part of its wider investigation, the HSIB found that there are no standards for what safety-critical functionality should be available in ePMA systems used in paediatrics (for example, the use of weight-based dose bands, where individually calculated doses are rounded to a set of predefined doses).

"Also, local configuration of ePMA systems potentially introduces variability and risks if not undertaken with clear understanding of the potential hazards and their mitigations. The issue of configuration was a key issue in this investigation and the previous one published in 2019."

The findings of this investigation would suggest there is a need for increased awareness among the medical community about the limitations of ePMA systems, the HSIB acknowledged. "We found that clinicians perceived the ePMA system would be capable of 'catching' their errors, so causing an over-reliance on the system. Other clinicians viewed the ePMA system as an electronic version of the paper chart, and expected the prescribing functionality would be similar, which was clearly not the case. The issue of workarounds has been highlighted to us too, both in this investigation and a previous one, which then requires re-training of staff, system modifications, and so on,” the HSIB spokesperson told Medscape UK.

Adult Care

The 2019 HSIB report identified a significant safety risk regarding the prescribing of high-risk medication using both electronic and paper systems, spanning primary and secondary care.

The reference event involved a 75-year old woman with terminal cancer who was left taking two powerful anticoagulants at the same time after being discharged from her local hospital.

This investigation highlighted that incomplete use of ePMA systems could create further risks to patient safety. The HSIB made four safety recommendations to NHSX, one to the Department of Health and Social Care and one to NHS England and NHS Improvement as a result of this investigation.

"From this investigation we found that there was limited knowledge and data relating to unintended consequences of introducing ePMA systems because of the varied nature of health IT products and the lack of common criteria against which to measure the impact. We also found that commercial ePMA systems reduced medication errors if the available functionality was switched on, used appropriately, integrated with other relevant IT systems and aligned with clinical workflows, the HSIB spokesperson told Medscape UK.

They added that the implementation of their recommendations from both investigations should enhance the safety of ePMA systems.

What Now?

As the roll-out of ePMA systems continues apace across NHS trusts, there are number of factors that are crucial to their successful adoption and to ensure the maximising of patient safety.

Ramandeep Kaur

An expert on the rollout of ePMA systems in England, Ramandeep Kaur, lead ePMA pharmacist, Barking, Havering, and Redbridge University Hospitals NHS Trust, said that careful preplanning and stakeholder engagement, "making sure that everybody is on board from the outset", is key to the successful implementation of any ePMA system. Furthermore, ensuring adequate training of clinicians and all relevant staff before rollout and having all the necessary resources in place is also vital, as changing to such a system marks "a massive, complex transformational change".

"I think one of the shortcomings often in organisations is not necessarily having the right resources, both from the implementation perspective, and post-implementation perspective, so it is business as usual," she said, adding that "flexibility and agility" are also key on behalf of trusts and clinicians, as well as ePMA system suppliers, to adapt to changing needs and improving any identified system shortcomings.

Kaur noted that there are over 20 suppliers of ePMA systems operating in the UK market, with a lot of variety, so interoperability with other systems is crucial.

Furthermore, whatever their functionality, ePMA systems don’t replace human interaction, she stressed. "You still need to be able to go out and speak to your patient and fundamentally in all the years I’ve been doing this, I’d still advocate the importance of speaking to the patient, speaking to the clinician, being out on the 'shop floor' as it were to have those conversations and not solely rely on the system. Because with these systems you can have certain levels of clinical decision support and system alerts, but you can end up with alert fatigue… so people can end up ignoring those flags."

Kaur concluded by saying that the main benefits of ePMA systems "are qualitative and about doing what is right for our patients".

"The fundamental element is about improving patient care, that is the bottom line. There is no system or organisation that is perfect, but equally it is how can we adapt to ensure that you can utilise that [ePMA] system within the realms of your organisation to make it work. There is always improvements that can be made."

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