05 Nov eMAR: 8 Things To Look For (And Avoid) In A Good System
While electronic medicines administration records (eMAR) are without doubt the way forward, no system is perfect. To help you chose an eMAR, we’ve put together a ‘snagging list’ of common issues we’ve seen.
Is the medicine entry laid out logically?
Does the system include all 3 descriptors for the medicine: medicine name, strength and form? Many systems fail to record form, i.e. whether it is a tablet, a capsule, a cream etc. Does the system use use the term ‘dose’ instead of strength and directions? Dose is a term prescribers and pharmacists use, for example 500-1000mg as a single dose, or max 4000mg in 24 hours. In this example, what would you write in the ‘dose’ box? “1”, “500mg”, “500mg-1000mg?’ ‘1-2 tablets’? We have found that it is far better to record the strength of the tablets: “500mg” and then the directions “ONE or TWO tablets FOUR times a day” If the key information needed to carry out the medicines cross check (medicine vs MAR) is not in a logical place on the MAR, will staff make those proper checks? Scanning bar codes is probably best, but not every medicine comes with a barcode, such as hospital discharge medicines, or the barcode could be torn, smudged or otherwise damaged. If they depended on simply scanning a code, would staff de-skill and lose their ability to carry out adequate medicines cross checks should the eMAR device be unavailable? And sometimes barcodes just take a long time to scan, requiring repeated attempts before the record is successfully updated.
Is the system flexible enough?
If the client isn’t ready for their medicines, or if they decline them at the moment they are offered and you want to try again, can you leave the entry blank and return to administer and record their medication later on?
It is easy to access PRN protocols, body maps, and other forms?
Do the forms on the system contain the level of detail you need? Can you add additional fields and remove those you don’t want? Does it take lots of clicks to find to find the form? The forms need to be ‘at hand’ so, for example, the link to the form should be right next to the PRN medicine or cream. If that’s not the case, will staff refer to them when needed?
Can you ‘pop’ and ‘dot’?
With paper MARs, after we have checked that the medicine is correct (the medicines cross check confirms the MAR matches the medicine), we can dispense (pop it) it into the pot and then dot the MAR (in the dosage field). This means you are able to prepare more than one medicine at a time, and know where to sign afterwards. Does the eMAR you’re looking at allow for this?
Does eMAR really reduce medication errors?
I’ve seen many claims that eMAR reduces errors, but little to no firm data for that so far. Sure, you won’t have gaps on your MAR charts anymore, but I’ve seen occasions where staff have tapped ‘administered all’ on the eMAR when the client had declined one of the medicines. I’ve also seen times where staff have marked doses as ‘taken’ before even giving the dose.
If the system uses bar codes, and assuming the data entry was correct in the first place, then this should stop human selection error (medicine does not match MAR). However, not all medicines will be barcoded (ask yourself, do all hospital discharge medicines come with barcodes?), what if the barcode is torn or smudged? And will staff de-skill, unlearning best practices through not routinely implementing them? That may not be an issue, until you get to point below.
Additionally, not all medication errors are selection errors or gaps on MAR charts (see our workshop – Managing and Learning from Medication Errors where we teach root cause analysis.)
What happens when the lights go out?
How does your new eMAR cope without power? or in WIFI / data blackspots? Will it carry on recording? We have recently seen an error occur where two staff were administering in a care home when their eMAR went offline. Each of their laptops coped with the situation okay, and they recorded that the doses had been given. However, the laptops couldn’t communicate with each other in real time, which resulted in several residents being medicated twice.
Training
Most staff can figure out how to record on a paper MAR, even if the design varies a little. Electronic MAR systems have more features though, and it’s less likely you could use an eMAR effectively without prior training. While eMAR providers might train staff to begin with, what happens when those staff move on or are replaced? There needs to be continuous access to specialist training for each system.
Rubbish in, rubbish out!
We’ve seen incorrect doses entered into eMARs, and even duplicate medicines, where clients have entered ranitidine and Zantac, or salbutamol and Ventolin separately. To be fair to the eMAR systems the same errors could occur with paper MARs. However, you should bear this in mind if the eMAR company is telling you that their system will reduce, or even eliminate medication errors entirely.
CQC state that staff who enter medicines details into MAR systems (either paper or electronic) should be trained and competent in medicines reconciliation and transcription. We provide such training here: Medicines Reconciliation and Transcription Training.
John Greene BSc (HONS) Pharmacy
Lead Pharmacist and MD.