You take the red pill—you stay in Wonderland and I show you how deep
the rabbit-hole goes.
After Prescribe/Order and Dispense, the next workﬂow is Administer/electronic
Medication Administration Record (eMAR).
Being the last line of defense before reaching the patient, the Administer
workﬂow approach to safety is based on the 5 Rights: A safe drug administration
needs to validate the ﬁve parameters—Patient, Drug, Dose, Route, and Time—are
Using dataﬂow diagrams (DFDs), we decompose the Administer workﬂow
into processes, making sure the 5 Rights requirements are satisﬁed. During the
analysis, we will identify concepts, such as Automated Dispensing Cabinets, Bar
Code Medications Administration (BCMA) systems, and Smart pumps and their
interactions with the Medications system.
Following the analysis of the processes, we focus on the data needed to sup-
port the Administer workﬂow: discrete data elements that are part of the evolv-
ing Medications ERD (entity-relationship diagram) and data elements exchanged
with the actors.
A set of simple formulae clariﬁes the relationships between the various con-
cepts and units of measurement that are used during the Administer workﬂow
of a Continuous drip, such as Volume Rate, Concentration, Dose, Drop Rate, and
The chapter ends with a high-level view of an automated process for calculat-
ing dose parameters.
156 ◾ Electronic Health Record: A Systems Analysis of the Medications Domain
Prescribe, Order, and Dispense are workﬂows covered in previous chapters.
Following a prescription or an order and the dispensation of a drug (including
over-the-counter drugs), the next workﬂow is Administer. It is the last step in a
drug life cycle (Figure6.1).
The recommendation is to adhere to the traditional 5 Rights during the
Administer workﬂow and make sure only the Right
parameters are involved in a drug administration (1). Sometimes, a sixth right is
mentioned: the Right Clinician. We discuss several methods and systems to help
make the Administer workﬂow safer, more efﬁcient, while strictly adhering to the
The actual drug administration may necessitate ﬁrst pulling the medication
from a storage area. Next, there may be a need to further prepare the drug, such
as diluting its strength (2). The 5 Rights being addressed, a drug may be directly
administered or pass through a CDS (clinical decision support) ﬁlter. Bar code
and Smart pump systems, discussed further in this chapter, are technologies to
automate the validation process of the 5 Rights. Following actual administration
Pull drug from storage Prepare drug
Monitor effect Document
PRESCRIBE ORDER OTC
Figure 6.1 Drug life cycle: Administer workﬂow.
Administer/eMAR ◾ 157
of a drug, there are two remaining tasks: Monitor effect and Document the
In the following decomposition of the Administer workﬂow into its main pro-
cesses (DFD), we have to satisfy the 5 Rights requirements while integrating the
actors and processes mentioned.
DFD 4 Administer Workﬂow
We ﬁrst isolate workﬂow number 4 Administer/eMAR from the Medications sys-
tem (Figure6.2), which is represented as DFD 0 (Figure2.3).
Besides the ADMINISTERING CLINICIAN, who is usually an actor in an inpa-
tient environment, there is one other actor active in the Administer workﬂow: the
PATIENT, who may use the Medications system in general and the Administer
workﬂow speciﬁcally as his or her Personal Health Record (PHR), by keeping a
log ﬁle up to date with the medications self-administered at home.
The preconditions to DFD 4, which must be satisﬁed before system may pro-
ceed with the Administer workﬂow, are as follows:
1. Clinician is uniquely identiﬁed.
2. Clinician is authorized to use system in lieu of administering medications.
3. Patient is uniquely identiﬁed.
4. Patient is authorized to use system in lieu of self-administering medications.
5. All the system activities are logged.
Figure 6.2 Administer workﬂow: Isolated from DFD 0.