Presentation
Implementing a Successful Medication Verification Process in the ED: Lessons Learned from a Level I Trauma Center Serving a Rural Population
SessionPoster Session 2
DescriptionObjective: Evaluate the impact of implementing prospective medication order review in the emergency department (ED) at a rural, level 1 trauma center.
Background: The estimated national rate of medication errors in the ED ranges from 3% to 14%, many of which are considered preventable, with an associated annual cost exceeding $3.5 billion1-3. Prospective medication order review requires pharmacists to assess medication orders prior to dispensing or administration in inpatient settings. A survey of 562 hospitals found that only 20.2% of hospitals had pharmacists review medication orders before the first dose was administered in the ED4. Given this limited adoption, a 2007 Joint Commission clarification permitted exceptions to prospective review in emergency situations or when delays in administration could result in patient harm5. While benefits of prospective order review are well-documented, its implementation in emergency departments remains limited especially in rural health systems.
Setting: This rural, trauma level 1 healthcare system serves a large geographic area in the Rocky Mountain region of the United States. As a community teaching hospital (330+ beds), the facility provides critical, integrated multi-specialty care represented by more than 80 specialties. The hospital’s primary surrounding 3-county area is within a metropolitan core of ~170,000 residents that includes seven rural and two small town census tracts. The average population density is 2,272 but ranges from 3.4 to 5,789 persons. Accordingly, this hospital services a uniquely large geographic coverage area from extremely rural and sparsely populated to a densely populated city core. Like many rural health systems, challenges exist to provide sustainable health care access, attract and retain highly skilled workers, leverage technological innovation, and rapidly integrate innovative care models.
Implementation: Beginning in 2017, the 36-bed ED operated with part-time pharmacist coverage, and prospective order review currently limited to anti-infective agents only. Prior to requirement of prospective review, any medication available in the ED automated dispensing cabinet (ADC) could be dispensed by nursing staff, without any override requirements. At the go-live for prospective order review, anti-infectives could no longer be dispensed without pharmacist verification. All other medications were categorized as non-emergent or emergent. Medications deemed to be non-emergent then required nursing staff to select an override reason if medications were dispensed from the ADC prior to pharmacist verification. Medications categorized as emergent remained available from the ADC, without requirement for an override reason.
After receiving Trauma Level I certification, the interdisciplinary team of physicians, pharmacists, nurses, data scientists and researchers, assessed the possibility of expanding prospective order review from the anti-infectives to the larger set of the ~4,000 medication orders placed by ED providers each month. Using retrospective chart review, the interdisciplinary team found that there were significantly quicker process times from order entry to administration for the anti-infectives (no delays!). Given these positive results, the pharmacy department altered ED coverage with a dedicated pharmacist in the ED from 0930-0200 on weekdays and 1530-0200 on weekends and holidays. During this period the ED averaged 137 ED patient visits per day. Beginning in 2024, an expanded set of medications were chosen through review of the ED ADC inventory, the ADC Override Decision Tree, and consultation with ED nursing staff. An additional 101 medications, representing ~60% of all medications in the ADC, required review. With this implementation, the team conducted a retrospective chart review combined with a prospective observational study to confirm the effectiveness of prospective order review in the ED on medication process times and patient length of stay. The pre-intervention (control) and post-intervention study groups included patients who received an included order from December 1, 2023 to March 31, 2024 and December 17, 2024 to February 28, 2025, respectively.
Results: The pre-intervention group included 1,070 patients admitted to the ED with a total of 1,431 medication orders. The post-intervention group included 735 patients admitted to the ED with a total of 974 medication orders. There was no significant difference between the control and intervention groups in average time from order entry to medication administration (37 ± 37.8 minutes vs. 39.7 ± 41 minutes; p=0.095), order entry to verification (5.99 ± 7.8 minutes vs 5.69 ± 6.1 minutes; p=0.298), order verification to medication dispensing (21.4 ± 30.4 minutes vs 23.7 ± 34.2 minutes; p=0.099), and medication dispensing to administration (10.8 ± 19.1 minutes vs 10.4 ± 18.3 minutes; p=0.631). The ED ADC override rate decreased from 6.89% in the control group to 4.55% in the intervention group for all medications in the ADC (p<0.001) - dropped to 0 (0%) for those medications specifically targeted for prospective review.
Application: Although there are concerns about potential delays, especially in critical care settings like the Emergency Department (ED), prospective review is a well-established standard and serves as a critical intervention point within the medication-use process to enhance medication safety. Implementation of prospective order verification by pharmacists for non-urgent medications in the ED did not impact the time from order entry to medication administration, further supporting implementation of this practice to ensure safe and appropriate medication use without causing delays in patient care.
References:
1. Weant KA, Bailey AM, Baker SN. Strategies for reducing medication errors in the emergency department. Open Access Emerg Med. 2014;6:45-55. doi:10.2147/OAEM.S64174
2. Pham JC, Story JL, Hicks RW, et al. National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors. J Emerg Med. May 2011;40(5):485-92. doi:10.1016/j.jemermed.2008.02.059
3. Patanwala AE, Warholak TL, Sanders AB, Erstad BL. A prospective observational study of medication errors in a tertiary care emergency department. Ann Emerg Med. Jun 2010;55(6):522 doi:10.1016/j.annemergmed.2009.12.017
4. Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Dispensing and administration--2014. Am J Health Syst Pharm. Jul 1 2015;72(13):1119-37. doi:10.2146/ajhp150032
5. Assabahi, Amirah, et al. “Development and Implementation of Autoverification Best Practices.” American Journal of Health-System Pharmacy, 2025, https://doi.org/10.1093/ajhp/zxaf057.
Background: The estimated national rate of medication errors in the ED ranges from 3% to 14%, many of which are considered preventable, with an associated annual cost exceeding $3.5 billion1-3. Prospective medication order review requires pharmacists to assess medication orders prior to dispensing or administration in inpatient settings. A survey of 562 hospitals found that only 20.2% of hospitals had pharmacists review medication orders before the first dose was administered in the ED4. Given this limited adoption, a 2007 Joint Commission clarification permitted exceptions to prospective review in emergency situations or when delays in administration could result in patient harm5. While benefits of prospective order review are well-documented, its implementation in emergency departments remains limited especially in rural health systems.
Setting: This rural, trauma level 1 healthcare system serves a large geographic area in the Rocky Mountain region of the United States. As a community teaching hospital (330+ beds), the facility provides critical, integrated multi-specialty care represented by more than 80 specialties. The hospital’s primary surrounding 3-county area is within a metropolitan core of ~170,000 residents that includes seven rural and two small town census tracts. The average population density is 2,272 but ranges from 3.4 to 5,789 persons. Accordingly, this hospital services a uniquely large geographic coverage area from extremely rural and sparsely populated to a densely populated city core. Like many rural health systems, challenges exist to provide sustainable health care access, attract and retain highly skilled workers, leverage technological innovation, and rapidly integrate innovative care models.
Implementation: Beginning in 2017, the 36-bed ED operated with part-time pharmacist coverage, and prospective order review currently limited to anti-infective agents only. Prior to requirement of prospective review, any medication available in the ED automated dispensing cabinet (ADC) could be dispensed by nursing staff, without any override requirements. At the go-live for prospective order review, anti-infectives could no longer be dispensed without pharmacist verification. All other medications were categorized as non-emergent or emergent. Medications deemed to be non-emergent then required nursing staff to select an override reason if medications were dispensed from the ADC prior to pharmacist verification. Medications categorized as emergent remained available from the ADC, without requirement for an override reason.
After receiving Trauma Level I certification, the interdisciplinary team of physicians, pharmacists, nurses, data scientists and researchers, assessed the possibility of expanding prospective order review from the anti-infectives to the larger set of the ~4,000 medication orders placed by ED providers each month. Using retrospective chart review, the interdisciplinary team found that there were significantly quicker process times from order entry to administration for the anti-infectives (no delays!). Given these positive results, the pharmacy department altered ED coverage with a dedicated pharmacist in the ED from 0930-0200 on weekdays and 1530-0200 on weekends and holidays. During this period the ED averaged 137 ED patient visits per day. Beginning in 2024, an expanded set of medications were chosen through review of the ED ADC inventory, the ADC Override Decision Tree, and consultation with ED nursing staff. An additional 101 medications, representing ~60% of all medications in the ADC, required review. With this implementation, the team conducted a retrospective chart review combined with a prospective observational study to confirm the effectiveness of prospective order review in the ED on medication process times and patient length of stay. The pre-intervention (control) and post-intervention study groups included patients who received an included order from December 1, 2023 to March 31, 2024 and December 17, 2024 to February 28, 2025, respectively.
Results: The pre-intervention group included 1,070 patients admitted to the ED with a total of 1,431 medication orders. The post-intervention group included 735 patients admitted to the ED with a total of 974 medication orders. There was no significant difference between the control and intervention groups in average time from order entry to medication administration (37 ± 37.8 minutes vs. 39.7 ± 41 minutes; p=0.095), order entry to verification (5.99 ± 7.8 minutes vs 5.69 ± 6.1 minutes; p=0.298), order verification to medication dispensing (21.4 ± 30.4 minutes vs 23.7 ± 34.2 minutes; p=0.099), and medication dispensing to administration (10.8 ± 19.1 minutes vs 10.4 ± 18.3 minutes; p=0.631). The ED ADC override rate decreased from 6.89% in the control group to 4.55% in the intervention group for all medications in the ADC (p<0.001) - dropped to 0 (0%) for those medications specifically targeted for prospective review.
Application: Although there are concerns about potential delays, especially in critical care settings like the Emergency Department (ED), prospective review is a well-established standard and serves as a critical intervention point within the medication-use process to enhance medication safety. Implementation of prospective order verification by pharmacists for non-urgent medications in the ED did not impact the time from order entry to medication administration, further supporting implementation of this practice to ensure safe and appropriate medication use without causing delays in patient care.
References:
1. Weant KA, Bailey AM, Baker SN. Strategies for reducing medication errors in the emergency department. Open Access Emerg Med. 2014;6:45-55. doi:10.2147/OAEM.S64174
2. Pham JC, Story JL, Hicks RW, et al. National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors. J Emerg Med. May 2011;40(5):485-92. doi:10.1016/j.jemermed.2008.02.059
3. Patanwala AE, Warholak TL, Sanders AB, Erstad BL. A prospective observational study of medication errors in a tertiary care emergency department. Ann Emerg Med. Jun 2010;55(6):522 doi:10.1016/j.annemergmed.2009.12.017
4. Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Dispensing and administration--2014. Am J Health Syst Pharm. Jul 1 2015;72(13):1119-37. doi:10.2146/ajhp150032
5. Assabahi, Amirah, et al. “Development and Implementation of Autoverification Best Practices.” American Journal of Health-System Pharmacy, 2025, https://doi.org/10.1093/ajhp/zxaf057.
Authors
Event Type
Poster Presentation
TimeTuesday, March 244:45pm - 6:15pm EDT
LocationRhinelander Gallery
Hospital Environments