San Antonio, Texas

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eMAR Bar CodingPractice Recommendations and
Project Learnings

• San Antonio, Texas

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Project Risks

• Invalidating bedside verification with
  workarounds
• Packaging and labeling errors in pharmacy
• Changing federal regulations
• Emerging barcode symbologies

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The Solution ???

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Potential Project Impacts

• Reviewing/ re-engineering the delivery and
  administration of medications
• Redistributing work loads
• Changing work flow
• Creating virtual medication teams

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Who is impacted . . .

• Pharmacy
• Nursing/ Respiratory Therapy
• ITS
• Others
• HIM
• Physicians
• Ancillary Departments

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Pharmacy Impact

• Accuracy and timeliness of order entry and turn
  around
• Bar Coding ALL medications
• Medication acquisition philosophy

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Quality Control Practice Recommendations

• Bar Coding
• Acquisition
• System Integrity with NDC
• Distribution
• Must include staging area

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Multi Dose / Multi-Use Medication Practice
Recommendations

• Insulin
• Inhalers
• Large Volume IVs

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Nursing Impact

• Model of care delivery
• Who do you want to give medications?
• Medication distribution system
• How do medications get from the pharmacy to the
  bedside?

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Quality Control Practice Recommendations

• Order Acknowledgement
• Electronic Medication Administration Record sign
  off
• Impact to Chart Check
• Timely error prevention

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Pediatric/NICU Practice Recommendations

• Identify armband solution
• Pre-registration Processes
• Unit dose medications
• Address equipment issues
• Explore other uses for bar code technology

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Breast Milk Practice Recommendations

• Ensure appropriate mike gets to correct baby
• Assign barcode to milk and utilize barcode on
  armband
• Ensure QC process occurs

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Respiratory Therapy Impact

• Medication Administration
• Workflow
• Medication distribution system
• How do medications get from the pharmacy to the
  bedside?

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Respiratory Therapy Practice Recomendations

• Must have complete order or approved protocol
• Determine who will acknowledge/sign off orders
• Flow diagram process for RT orders from order
  written to treatment delivered

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Respiratory Therapy Practice Recommendations

• Determine process for inhalers
• Flow diagram process for bar coding and
  distribution of RT meds
• Use medications that have manufacturer barcodes
  where possible
• Enter as scheduled by physician

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ITS Impact

• New Member of the Clinical Team
• WLAN Installation and Support
• Computer Management
• Equipment Maintenance, including pharmacy
  equipment

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• General
• Practice
• Recommendations

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Infection Control Practice Recommendations

• Carts should be cleaned at least daily with
  hospital approved disinfectant
• Carts may be used in isolation rooms
• Carts should be cleaned before leaving the room
  if contaminated and when used in isolation
• Patient Safety equipment can be safely used in
  all patient care areas exception Known SARS
  or Small Pox

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Armband Practice Recommendations

• Ensure that CODE 128 bar code is being used for
  armbands
• Ensure that ALL armbands use bar code that is
  compatible with eMAR at all points of entry (ER,
  Admitting, etc.)
• Train staff on correct application of armband and
  scanning techniques (Guides provided on eMAR
  website)

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Manager Practice Recommendations

• Reinforce the purpose of eMAR not the action of
  scanning
• Direct Observation
• Establish policies/procedures to address high
  risk behavior
• Implement PI plan to improve scanning percentages
  beware of work-arounds
• Make it easier to use the system than engage in
  work-arounds

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Culture Practice Recommendations

• Leadership Role
• Executive Walk rounds
• Observe nurses passing medications and observe
  patient verification by scanning
• Create an environment for nurses to feel
  comfortable reporting when patient verification
  is not being performed
• Use staff meetings and other opportunities to
  discuss barriers to verifying the patient and
  work on ways to overcome them

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Culture Practice Recommendations

• Reinforce with nursing the purpose of eMAR and
  the need to verify the patient with each
  medication administration
• Regardless of how long they have known the
  patient, how many patients they have or how
  confident they arethe system is flawed, mistakes
  will occur

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Healthcare is fraught with complex processes,
nonstandard procedures, and individual latitude
in execution.
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Patient Safety Theory- Blunt and Sharp End
Policies, procedures, resource allocation systems
Blunt End
Direct caregiver
Sharp End
ERROR
Monitored Process
Results
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eMAR Process Maintenance???

• Software
• Equipment
• Culture/process change

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Evolving

• Software
• Future Development
• Allergy Integration
• Armbands
• Downtime
• Integrated issues list
• Usage in areas without pharmacist review
• Software
• Equipment

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Additional Considerations

• Clinical interface integration
• Smart Pumps Integration
• Dynamap
• Glucometer findings
• Workflow study on human factors integration