Through thick and thin; A novel eMR solution for thickened fluids and non-compliant medications
Katie Beckett1, Georgina Rosee, Linda White 1Central Coast Local Health District (cclhd), NSW, Australia
Abstract
A Root Cause Analysis identified contributing factors to a fatal aspiration pneumonia following provision of thin fluid medication to a dysphagic patient who had been recommended thickened fluids only. The electronic medical record (eMR) did not link thickened fluid status to medication prescriptions, allowing non-compliant liquid medications to be ordered for patients at risk of aspiration. Furthermore, there was no resource to guide alternative administration or medication forms when a dysphagic patient on thickened fluids required a liquid medication.
A diverse project group of health care workers (HCW’s) and IM&T developed two key initiatives to reduce the risk of dysphagic patients aspirating on liquid medications. They designed and implemented 1/ automated eMR solutions to alert clinicians ordering diets or prescribing medications of a mismatch in compliance of liquid medications with thickened fluids and 2/ a guideline for prescribers outlining alternative medication forms or safe administration options when a dysphagic patient requires a liquid medication. Following implementation, a 6-month snapshot showed 1278 alerts generated when a new thickened fluid order was incompatible with prescribed medications and 1298 alerts when medications were prescribed that were incompatible with current thickened fluids. The local guideline has been accessed hundreds of times since its publication.
This project demonstrates the value of diverse disciplines working together to harness technology in developing effective and sustainable patient safety solutions.
Biography
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