Implementation of an Electronic Medication Administration Record using Bar Code Technology A collabo

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Implementation of an Electronic Medication
Administration Record using Bar Code
TechnologyA collaborative project between
Pharmacy, Nursing, Respiratory Care and
Information Systems.Presented by Sue Ebertowski
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• A licensed 760 bed facility
• 442 beds are considered operational
• Tertiary care facility
• Owned by HCA-the Healthcare Company
• Level 1 Trauma Center

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Background

• The problem area to be studied is part of a
  corporate wide patient safety initiative to
  improve medication administration. While its
  believed that medication errors are reported,
  literature would indicate an under reporting.
  Implementing an electronic medication record with
  bar code technology attempts to eliminate the
  potential 38 administration errors.

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Background, continued

• WMC is located within a community where Boeing
  has a large employee base. Boeings involvement
  with Leapfrog and WMCs desire to meet the
  Leapfrog criteria were a significant factor in
  seeking acceptance into the corporate initiative
  in 2003. WMC recognizes that the Leapfrog
  criteria specifically addresses computerized
  order entry, however it is in its infancy stages
  within the corporation. This is the first step.

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E-MAR

• Electronic Medication Administration Record
• Every Med administered Right!
• (HCA, 2001)
• BCMA
• Bar Coded Medication Administration

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Statement of the Problem

• Physician ordering and transcribing of
  medications are responsible for 39 and 12 of
  medication errors respectively.
• 48 of these errors are discovered before
  reaching the patient.
• Administration of medications accounted for 38
  of medication errors with only 2 discovered
  before reaching the patient. (Leape,L. 1995)

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The Problem further defined

• Medication errors are frequent occurring at a
  rate of nearly 1 of every 5 doses in typical
  hospital.
• 7 of errors rated potentially harmful.
• Medication delivery and administration systems
  have major system problems.
• Errors understated due to self reporting
  systems.(Barker, et al 2002)

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More Problems

• Incident reporting is a self reporting system so
  number of medication incidents probably
  understated.
• Nurses report medication incidents that they
  perceive as serious and are less likely to report
  those they perceive as not serious.
• (Osbourne, et al 1999)

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Types of medication errors at WMC

• Level 1 errors include those that may have
  capacity to cause harm, Near Misses and No Harm
• Level 2 errors have a need for increased
  monitoring or treatment.
• Level 3 errors cause increased LOS or Death

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Expected Outcomes

• WMC will reduce its Level 2 and 3 medication
  errors through the implementation of Bar Coding
  technology and an Electronic Medication
  Administration Record (EMAR).
• WMC will experience an increase its Level 1
  errors with the implementation of Bar Code
  Technology and an EMAR.

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Relationship of Adverse Drug Event, Adverse Drug
Reaction and Error
This includes all errors, ranging from trivial
(late med) to serious injury
STOP This includes errors that reach patient, and
result in injury and/or reaction and are
preventable. Level 2-3 errors
Med Errors Level 1 errors
ADEs and ADRs (error)
ADEs and ADRs (no error)
Potential ADEs/ADRs
SLOW These are near misses, or errors caught
before reaching patient
These are injuries or reactions that were not
related to error and were non-preventable Level
2-3 errors
Adapted from Bates DW et al. J Gen Intern Med
1995 10199-205.
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Reported Med Errors per 100 Adjusted Patient
days
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Errors resulting in ADEs Harvard Study
Electronic physician order management
Bates DW et al. Incidence of adverse drug events
and potential adverse drug events. JAMA
199527429-34.
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Related Research

• Veterans Administration Hospitals have 10 years
  of history with Bar Coded Medication
  Administration.
• Colmery-ONeill VAMC reduced its errors from 21.7
  incident reports per 100,000 units in 1993 to 7.7
  incidents reports per 100,000 units in 1999. They
  reported a 64.5 improvement in medication error
  rates from 1991 over 1993 (Malcom,et al)
• VAMC in Topeka, KS reduced its medication error
  rate by 60 after BCMA implementation.
  (Neergard,2000)
• Martinsburg VAMC experienced a 24 reduction in
  errors. (Coyle and Heinen, 2002)

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Related Research, continued

• In another Government hospital, Low and Belcher
  found an 18 increase in medication error rate
  per 1000 doses in the month of implementation but
  found no statistical significance in the
  increase.

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Measuring the impact of eMAR and Bar Coding
Technology
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Measuring the impact of eMAR and Bar Coding
Technology, continued
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Measuring the impact of eMAR and Bar Coding
Technology, continued
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Measuring the impact of eMAR and Bar Coding
Technology, continued
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eMAR/Bar Coding Is . . .
Barcoded Patient Armbands
Electronic Safety Checking
Bedside Scanning
Barcoded Medication Doses
Electronic Medication Administration Record
HCA 2001
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Barriers to EMAR and BCMA

• Only 8 of hospitals use bar coding and scanning
  technology
• No universal bar code symbology
• Expense of implementing
• Lack of industry prepared bar coded packages
• Cost of in house repackaging
• Bar coding of IV admixtures
• Non-bar coded doses such as ointments, partial
  dose meds, inhalers. (Tech Knowledge, 2002)

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Advantages of BCMA

• Real time updates allow providers to alter
  medications and adjust delivery schedules with
  ease.
• Simultaneous access to the system at multiple
  sites insures that medication administration is
  not delayed by a nurses inability to view a
  chart that a physician is viewing.
• BCMA allows RNs to order refills at the push of
  a button, eliminating phone calls and paperwork.
  (Patterson, E. et.al 1995)

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Unintended side effects of BCMA

• During busy periods, RNs override the BCMA
  system to save time. Most often nurses typed
  patient identifier rather than scanning.
• The automated removal of medication after their
  administration time had passed confused the
  nurses which could contribute to missed doses.
• RN- Physician coordination is degraded under
  the BCMA, a side effect that the physicians
  attributed to the time-intensive process in
  checking the medication record.

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Unintended continued

• RNs became nervous when required to type an
  explanations for late meds.
• Systems lack of flexibility made it difficult to
  change dosages or taper orders. (Patterson, et
  al, 1999)
• Nurses found the system more time consuming than
  manual systems.
• Average age of nurses makes BCMA difficult and
  frustrating for RNS due to lack of familiarity
  with computers. (Health Care Advisory Board
  Watch interview, 2/11/03. Johnson, C. et.al.,
  Journal of Information Management, Dec 2001.)

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Nurse identified problems with BCMA

• Usability problems
• Contradictions between written medication record
  and BCMA data.
• Discrepancies between intended and scanned meds
• Coordination problems among staff
• Failure to find errors in BCMA
• Confusion stemming from automated BCMA actions.

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Nurse identified problems with BCMA, continued

• Requests for missing medications from pharmacy
  through BCMA.
• Unexpected Information updates
• Inaccessibility of BCMA during system down times.
• Differences between automated time stamp and
  administration time.
• Failure of BCMA to detect discrepancy between
  intended and actual patient.
• Unexpected updates received in BCMA. (Johnson,et
  al, 1999)

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electronic MAR Bar coding
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Implementing eMAR/Bar Coding
Prerequisites
Equipment Decisions
Budget Considerations
Staff Resources
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Key Considerations in Implementation

• Wireless Environment
• Requires a 802.11 wireless environment. Plan for
  expense to prepare the environment and the
  expense of the wiring.

• Interfaced Computer systems
• Source of medication profile is the Pharmacy
  Information system.
• Cost to interface the pharmacy system and the
  clinical documentation system must be evaluated.

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Key Considerations, continued

• Scanners
• Scanners must be able to read multiple bar code
  symbology including armbands, drug packages, and
  staff ID numbers.
• Must be durable and cleanable.

• Computers
• Determine if computers will be located in the
  patient rooms or on mobile carts.
• Determine type of PC to be used.
• Determine the number per floor.

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Key considerations, continued

• Packaging issues
• Determine if will outsource repackaging of drugs
  and liquids or if will repackage at medical
  center.
• Bar coding of packages to read by scanner

• Name Bands
• All name bands must be bar coded.
• Placement of the name bands must now face toward
  the nurse like shaking hands.
• Size of bar code and pediatric and neonatal
  patients.

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Key Considerations, continued

• Hardware
• Verify adequacy and quality of bar code label
  printer
• Software
• Meditech software is the software which is being
  used for the project

• Staffing
• Number required to develop program
• Determine which unit to begin implementation
• Education of all staff in learning environment
  not necessarily the patient room
• Implementation plan
• Additional maintenance

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Other Key Considerations

• Process problems
• Mixing of meds at bedside required. Problems on
  Pediatrics (needles in front of kids) and supply
  management (having everything at bedside.)
• Double checks of medications How to secure the
  second signature.
• Requires standardizing operations across the
  hospital not just departments.
• NPO status
• Meal times have to be the same for with meals
  consideration.

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Other Key Considerations

• Saline flushes now have to have an order so can
  be scanned into computer. ( A huge physician
  dissatisfier)
• Near misses explanations have to be scripted.
• Medication refusals will have different
  considerations.
• Information Systems may need to be available 24
  hours for IT support
• Name bands must be applied properly and
  maintained- no twisting, bending, or dirty bands.

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Progress Thus Far!
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New Storage Needs

• All meds bought in bulk and repackaged
• Increased storage needs.

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New Packaging

• Multiple meds stored alphabetically in drawers in
  carousel

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Examples of Bar Codes for different type drugs
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The Fluids Packer

• All liquids bought in bulk.
• All liquids packed, labeled and bar coded by
  packer.

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One of the Pill Packers

• Bulk pills packaged by pill packer.
• Medication labels generated with the aid of the
  computer
• 3000 doses per hour

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The Nurses Med Cart

• Each person who administers medication assigned
  cart.
• Each cart contains a laptop and bar code reader.
• Carts adjust for ergonomics
• Box on bottom stores supplies

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Progress Report

• Pharmacy completed storage renovation.
• Pharmacy reviewed formulary and drug dictionary.
• Pharmacy began packaging bar coded packages.
• Laptops are ordered
• Internal processes are being reviewed.
• Mobile carts are ordered.
• Beginning work on Near Miss and Med Error
  reports.
• Discussing education plan for nursing and
  respiratory care.
• Billing processes being reviewed.
• Revised go live date August 2003

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Study Limitations

• Multiple decisions made at corporate level.
  Software, equipment, to name a few.
• Unable to complete data analysis due to equipment
  issues.
• Implementation dates assigned based on corporate
  availability.

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Apology!

• This project was on target until February when it
  was decided that WMC would wait for new upgraded
  Stinger mobile carts. The old model had been
  updated and was awaiting UL approval. Had
  implementation stayed on target, data would have
  been available regarding improvements. The
  upgraded carts were a better choice for our
  facility so we chose to wait. The UL approval was
  finally received in March, with a 12 week delay
  in delivery. Consequently the project has not
  been fully implemented.

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References

• Leape, Lucien L., et al. System Analysis of
  Adverse Drug Events. Journal of the American
  Medical Association, 274, 1995.
• Brennon, Trayen A. Leape, Lucien L. Laird Nan
  M. et al. Incidence of adverse and negligence
  in hospitalized patient Results of the Harvard
  Medical Practice Study I. N. Eng. J. Med.,
  324370-376, 1991.
• Nadzam, Deborah M. Development of medications
  use indications by the Joint Commission on
  Accreditation of Healthcare Organizations. AJHP.
  481925-1930, 1991.
• Osborne, Joan Blais, Kathleen Hayes, Janice
  Nurses perceptions When is it a Medication
  error. Journal of Nursing Administration. 29(4)
  April 1999. pp 33-38.

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References

• http//www.usp.org
• Low, Deborah K., Belcher, Jan V. Reporting
  medication errors through computerized medication
  administration. Computers Informatics Nursing.
  Pp 178-183, September/October 2002.
• Neergard, L. Hospital devising new ideas to cut
  medical errors. Available at http//www.nandomti
  mes.com. Accessed April 28, 2003.
• Sarudi-Scalese, Dagmara. Medication Safety Bar
  Coding The Forgotten Technology. Hospital and
  Health Networks. April 2002.
• Bar Code Medication Administration Tech
  Knowledge. Volume I, Issue 5. June 2002.
  Pharmacy Healthcare Solution. http//www.mederror
  s.com
• Johnson, Connie L., Carlson, Russell A., Tucker,
  Chris L., Willlette, Condore. Using BCMA
  software to improve patient safety in Veterans
  Administration Medical Center.

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References

• Coyle, Geraldine A. Heinen, Mary. Scan your
  way to a comprehensive electronic medical record.
  Nursing Management. 33(12) 56-59, December
  2002.
• Barker, Kenneth N. Flynn,Elizabeth A. Pepper,
  Ginnette Bates, David Mikeal, Robert.
  Medication errors observed in 36 health care
  facilities. Archives of Internal Medicine, Sept.
  9, 2002. v 162 il6 p1897 (7)
• Patterson E., et al., Improving patient safety
  by identifying side effects and introducing bar
  coding in Medication administration. Journal of
  American Medical Informatics Association, Sept
  Oct 2002, 9 (5), 540-553.
• Johnson, C., et al.,Journal of Healthcare
  Information Management. December 2001.