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Managing ePrescribing in usereducing their patient safety function and, in some cases, stopping becoming part of the ward team. Even when pharmacists still visit the wards it was sometimes reported that they spent much of their time there at the computer.
Changes in communication
“What we used to have in my last hospital, which I liked …you used to know your ward pharmacist and they would have little post-its and if you wanted to discuss something... you would ring them when it was convenient, whereas here it is quite a detached phone call.” [Junior doctor]
When we asked pharmacists, nurses and doctors if ePrescribing has changed the way they communicate with others the response varied. In our survey, most thought communication had stayed the same, some thought it had increased, and a small number that it had decreased.
“More as we do a lot of hand holding in clinics and run the medics training.”
[Pharmacist]
“Less - you don’t need to communicate or interact if you can message or propose but there is an audit trail. Interactions often don’t provide an audit trail to prove the interaction happened.” [Nurse]
Two people told us that ePrescribing had led to less interaction with other health professionals. At their trust, the fact that charts can be reviewed remotely, so staff did not need to come to the pharmacy, and that pharmacy staff could leave messages for doctors and nurses without needing to come to the ward, were seen as advantages because all these activities could be audited by the ePrescribing system.
Other sites had differing perspectives, with some acknowledging the need to make sure that there were still appropriate opportunities for face-to-face interactions between healthcare professionals and staff – and patients.
Security and PINs
“I still have my PRHO mnemonic because I went on the system as that. So sometimes you get a phone call saying, I know you’re only a House Officer, what are you prescribing this for?” [Doctor]
There are several security protocols for accessing ePrescribing. The one you choose needs to trade-off theoretical with practical security benefits. It also needs to trade- off security with staff time spent on tasks, and their consequent (dis)satisfaction and motivation to create less secure workarounds. Some hospitals had multi-level ID entry with a mnemonic login and a PIN they entered each time they actioned an order. Others
CHAPTER 7
Managing ePrescribing in use
had just one login but with a short active time so staff could not wander off and leave a screen open for others to use.
Who has responsibility for issuing ePrescribing passwords is also variable. In some sites, the Information Technology (IT) department had this role while in others, trainers, or ‘super users’ issue logins, or a less formal system with ward sisters able to issue a “single shift” login. It is worth seeing if there is the opportunity for using the same sign-ins to other systems, so that for example the same code is used to access ePrescribing, PAS etc. The frequency with which logins and PINs (personal identification numbers) were
changed also varied, and procedures for cancelling logins for staff leaving the Trust were not clear. Frequent changes provided extra security - but also posed memory problems, with some staff writing PINs on their hands, or on the back of ID badges. Some prescribing ‘by proxy’ did occur when staff did not have (or had forgotten) their logins. If, for example, nurses have a 10 character PIN then it can slow down their working (particularly if it is decided PINS need to be entered frequently); this also encourages workarounds.
Removal of authority is as important as creating it. One junior doctor, who had
completed her pre-registration experience at an ePrescribing hospital then left, told us that she had come back to a more senior post and found that her old login still worked. Workarounds
As staff get used to their ePrescribing system, some of them start to find ways to make it do what they want, such as bending the rules on who does what. Sometime these tricks are the only way to get the job done, however they may also be safety time bombs. The good aspects of workarounds are that they can be a way of identifying how to do things better. Workarounds can be a way of helping re- configure the system (see next section) and make it more workable in day-to-day use. The bad aspects are that often the workaround can be a very inventive way of by-passing a necessary safety feature.
What is more, the people who develop them often have little knowledge about the system as a whole, and those with the system knowledge are unaware of the reality of daily practice. Workarounds need to be known about and monitored to ensure they are safe. We have identified the following examples of workarounds:
Barcoding bedside lockers rather than the patient
If the ePrescribing system is linked to barcoded patient identification and the barcode ID on the patient wristband will not scan in, then medications cannot be accessed. So the nurse prints off another barcode label and sticks it on the patient’s bedside locker or table, with all the associated risks.