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Royal Free London NHS Foundation Trust

Digital tools improving patient safety at the Royal Free London

Reducing risk to patients 

Reducing prescribing errors and medication-related harm is a priority for the NHS nationally. They have significant impact on patient experiences, outcomes and costs, not to mention the devastating effect to staff should something happen to a patient under their care. 

Royal Free London NHS Foundation Trust (RFL), like several organisations in the UK, are on a journey towards smarter care with an enterprise-wide, fully integrated electronic patient, or health, record (EPR). Their Cerner Millennium® EPR includes powerful electronic prescribing and medication administration (ePMA) functionality.

Giving the care team the best tools to safely treat patients enables them to deliver the minimum five rights of medication safety – right patient, right time, right drug, right dose, right route – to their patients throughout their care journey. This means the care team can treat people safely and effectively and provide a prompter discharge service once the individual is well enough to leave hospital.

Presenting at a recent conference focussing on reducing medication errors in hospitals, clinical informatics pharmacists Hannah Heales and Christy Troy from RFL shared how they use ePMA. They indicated some of the early benefits of their recent transition from paper documentation to going live with Cerner Millennium ‘Model content’. 

Clinical decision support is a powerful tool 

The ePMA solution in Millennium is equipped with powerful clinical decision support to help reduce risk and avoid detrimental interactions. Christy highlighted that decision support “offers huge gains for patient safety, particularly around drug-allergy and drug-drug interactions.”

Preventing high-risk drug-allergy interactions

Knowing your patient is essential to safe care. Millennium holds accurate and up-to-date information with patients’ allergies to specific medicines. If a member of the team goes to prescribe that, or any related medication, then the EPR will immediately flag the interaction to the care team prior to completion of the prescription. The prescriber can then determine, supported by prompts and additional information provided by the EPR, whether to proceed, amend, or abort.

In February 2019 alone, Royal Free had 73 incidences of a prescriber going to prescribe a drug to an allergic patient, only for the EPR to flag the risk of harm and prompting a change to the prescribing decision. Allergies to penicillin and cephalosporins were particularly prominent and prevented.

Avoiding harmful drug-drug interactions

Avoiding harmful combinations of complex medications is essential, but difficult on paper, or without the right information connected in real time. Drugs clashing with one another, or potentially re-administered beyond safe time or dosage limits, can cause serious harm to patients.

Embedded decision support alerts at the point of prescription is particularly beneficial for complex drug interactions, such as clarithromycin and simvastatin. These interactions can lead to an increased risk of myopathy, and potassium bicarbonate-potassium chloride and spironolactone that can raise patients’ potassium levels to dangerous levels, among others.

Sixty-four patients’ prescriptions were stopped where a drug-drug interaction was flagged over the same single month, enabling prescribers to alter their decision based on reliable, timely information at the point of need, and safely prescribe alternatives.

Between clinical decision support for drug-allergy and drug-drug interactions alone, the EPR identified 140 at-risk RFL patients within a single month. With approximately 1,800 patients each year who may have been at significant risk from medication error, some with potentially severe consequences, the value of integrated ePMA within the EPR is clear. The team at RFL can now treat their patients more safely and with confidence, thereby reducing risk and improving outcomes.

Royal Free London NHS Trust

While the priority is patient safety, there are significant financially implications. Reducing unnecessary length of stay can save costs that can then be redirected back into other priority areas. According to Wiffen et al (2002) avoidable adverse drug reactions, on average, add three days to a patients' length of stayi. With each additional excess bed day costing £346 per patientii, these 140 errors avoided in February could be extrapolated to £1.89million per year in avoidable bed days aloneiii

Improving prescribing of gentamicin 

RFL are particularly proud of their gentamicin calculator tool – functionality built by the Trust within Millennium to automatically calculate parenteral dosage of the medication, based on a patient’s weight, taking into consideration their renal impairment and local prescribing guidelines to adjust the dose to within safe parameters and avoid excessive and potential harmful dosage. The EPR then presents pre-built care plan options, followed by a pre-calculated dose for that patient, all done for the clinician.

“The gentamicin tool is really appreciated by all of our prescribers, it’s really helpful. With the previous paper-based system there was a greater risk of error – for example, of the wrong dose being given because the wrong weight was used. The new EPR really helped address this problem in the first few months after it was introduced.” 

Hannah Heales, lead clinical informatics pharmacist 

Royal Free London NHS Trust

Alert

Anti-microbial stewardship is another hot topic for NHS Trusts. An integrated EPR with embedded ePMA workflows, coupled with real-time drug and patient information, enables the team at RFL to closely monitor both their antibiotic usage, and their patients’ ongoing needs. 

For all antibiotic prescriptions, a range of criteria is built into the Millennium system, such as alerts 24 hours after prescribing, requiring the pharmacist to review, amend, discontinue, switch route or continue with antibiotics, as well as ‘hard stops’ after 72 hours and again after five days. This is designed to ensure that prescribers can stay on top of their patients’ antibiotic usage and requirement – increasing both safety and outcomes, as well as tackling anti-microbial resistance for future generations. 

Dose too close alert 

In Millennium, RFL’s anaesthesia module is fully integrated with their drug charts. Previously, having two different records on paper could lead to incomplete or missed information, concerning medications given to patients during surgery. Medications administered in theatres are now fully visible, immediately, on the electronic drug chart which ensures that the full care team has accurate information on the medications and the doses administered in theatre. A warning alerts the nurse on the ward if they try to administer a dose of a medication that the patient has received during surgery, therefore preventing the patient from receiving an overdose.

Dose range checking 

The clinical team have been able to build additional rules to protect specific cohorts of high-risk patients. Children, for example are one such group and rules have been designed and tailored for certain patients’ demographic or history within the EPR, helping them to account for a number of parameters, e.g. age, including pre-menstrual age; weight, body surface area and certain medical conditions. Where prescriptions are outside of these limits, such as giving an adult dosage to paediatric patients, then the EPR will alert the prescriber of the risk, as well as displaying the appropriate dose for that patient, right there on their screen where it is needed, before harmful action can be undertaken. 

Recording medication reactions in the existing patient journey is essential to both reducing risk in future care encounters and supporting the population of a lifelong health record to help avoid the same occurrence should they move care provider, clinician or area. If a patient has a drug discontinued due to an adverse reaction, Millennium’s ‘Yellow Card’ tool allows the clinician not only to record this information against the patient’s record, but also to electronically submit the medication, reaction and other regulatory details to the MHRA (Medicines and Healthcare products Regulatory Agency). Including the ability to report this information to the MHRA as part of the usual Millennium workflow, without the clinician needing to take extra steps to do so, leads to increased visibility of adverse drug reactions for the MHRA, enabling them to implement safety regulations for medications more quickly which helps improve future care experiences for all patients.

In addition to the immediate benefits to safety and care quality, all this information throughout the patient journey helps to streamline the pharmacy discharge process.

Royal Free London NHS Foundation Trust

Using data to improve services 

Using the CareAdmin functionality in Millennium, RFL are able to perform closed-loop medication administration. There are currently a number of steps that are essential for reducing medication errors and helping prevent harm to patients by meeting the five rights of medication safety.

Delivering the five rights of medication safety: 

  • Every patient is issued a barcode identifier wristband on arrival. 
  • A nurse going to administer a drug will scan the patient to ensure it is the right patient. 
  • On scanning, the medications due within a two-hour timeframe for that patient, will immediately be visible onscreen at the bedside. 
  • The nurse will then scan the barcode of the medication to ensure they have the right drug, the right dose, and the right route.

At any of these stages, if the EPR flags a conflict/mismatch, then the team are made aware and can act immediately. 

As with any large digital transformation project, the team note some challenges that they are working to overcome. Scanning compliance in some areas of the hospitals is lower than others, with Hannah identifying several reasons, including: 

  • Ongoing staff engagement, training and at-the-elbow support helps them understand and utilise the full capability of RFL’s ePMA workflows. 
  • Occasional lack of equipment on some wards, such as drug carts, so staff are unable to fully utilise the solution. 
  • Barcodes on boxed medications being hidden by dispensing information labels. 
  • Patients’ own medications not scanning. 
  • When original medication packs have been discarded, and the barcode was on the box, rather than the blister pack or medication itself. 

“At RFL, now we have a mass of information that we can use to improve our services.” 

Christy Troy, senior clinical informatics pharmacist 

While decision support and alerts are two huge immediate benefits of an integrated ePMA system, according to Hannah and Christy, so too are auto-completion of text, pre-populated dosing instructions, data collection, and prescribing plans. These are available to the care teams across the hospital – where clinical guidelines form part of the care plan and multiple orders can be placed with just a tick – and make real differences to patient care and clinicians’ experiences. 

Monitoring usefulness and ensuring appropriate governance 

Both Christy and Hannah recognise the importance of governance for determining appropriate alerts and changes. The team utilise the rich data available from Cerner LightsOn Network® to monitor usage and if alerts are being frequently overridden. This enables the ePMA team to ensure that the tools are continually adding value to the workflow and contributing to patient safety.

Should things not be working as anticipated, the Trust have a robust governance and clinical risk management process to ensure that proposed changes are vetted and approved by CCIOs, change leads and clinicians to determine their need and ensure that they support clinical best practice.

Next steps 

Using real-time information within Millennium, the team are working with Cerner to build ‘pharmacy priority lists’, a real-time tool that continually monitors and identifies priority patients, based on criteria such as high-risk medicines prescribed for a patient, total number of medications prescribed for a patient, age, as well as other measures. The tool is intended to help the pharmacy team across the Trust’s multiple sites to, as Hannah says, “move away from the ‘bay-to-bay’ working approach and be able to prioritise our patients properly and start seeing them based on their risk.” 

They will also implement advanced Medication Clinical Decision Support (mCDS), and roll out Millennium functionality across the Royal Free hospital site.

Cerner Model Experience

Model Experience condenses knowledge, intelligence and clinical expertise from over 20 NHS Trusts, including seven Global Digital Exemplars (GDE), and 27,500+ facilities around the world, along with almost 40 years of Cerner experience to help you transform the way you deliver care, while ensuring maximum benefits for your patients and organisation.  

Model Experience comprises of:

  • A pre-built, clinically rich ‘model’ EPR built on our industry-leading Cerner Millennium platform  
  • Streamlined implementation  
  • Pre-built training materials  
  • Continuous advancement methodology to deliver additional content and ongoing benefits  

i. Whiffen et al (2002). Adverse drug reactions in hospital patients: A systematic review of the prospective and retrospective studies (p.10). www.bandolier.org.uk/Extraforbando/ADRPM.pdf

ii. Reference costs 2017/18: highlights, analysis and introduction to the data. NHS Improvement (p.5 2018). https://improvement.nhs.uk/documents/1972/1_-_Reference_costs_201718.pdf

iii. Calculations: 140 incidents over 28-day period = (140/28*365) = 1825 incidents/year; multiplied by average added length of stay (1825*3) = 5,475 additional bed days/year; multiplied by cost per excess bed day tariff cost (5475*£346). Does not include litigation, additional orders/tests, transport.

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Client outcomes were achieved in respective settings and are not representative of benefits realised by all clients due to many variables, including solution scope, client capabilities and business and implementation models.