Bar coding helps hospitals reduce medication errors
Tracking error reduction proves challenging, but users are pleased
It seems only yesterday that new systems were unveiled and approved for the bar coding of medications, but today a number of facilities not only have instituted such systems but have track records substantial enough for them to judge their impact.
In facilities contacted by Healthcare Benchmarks and Quality Improvement, those judgments are universally positive. "It has gone very well," says Patsy Sublett, MSN, RN, BC, clinical systems manager for Danville (VA) Regional Health System, which bought its first unit in 2001. "We have averaged about 118 prevented errors a month," she explains.
"This clearly was the safest way to administer meds, which was our goal," adds Nancy Luttrell, RN, MSN, clinical nurse specialist, neuroscience, and director of nursing informatics at Our Lady of the Lake Regional Medical Center in Baton Rouge, LA.
René Harrigan, RN, director of IT&S and communications at Bayshore Medical Center in Pasadena, TX, also says the introduction of a bar-coding system "has gone very well."
Different systems, capabilities
The three facilities all have purchased different systems, and the system capabilities also vary. For example, Danville Regional uses a Siemens system called Med Administration Check, which the staff call MAC. Currently, it is being employed for acute care patients in the system’s 350-bed community hospital and in its 60-bed long-term care facility.
"All meds have a bar code on them, and the patient ID band also has one," Sublett says. "We have an online system, and when a nurse pulls up the screen, it highlights the meds to give. Then you scan all the meds, and if one is wrong, the system alerts you. If it is all right, you scan the bracelet and get an immediate warning if it’s not the right patient."
In fact she adds, the system ensures that all the five rights of medication administration (right patient, right route, right dose, right time, and right medication) are adhered to.
The first acquisition Danville made was armbands for patients of all sizes, so they could be scanned easily. "You also need a wireless network in place, which we already had, because the devices that display the information have to be mobile," Sublett notes. "The scanners are also wireless."
The scanners cost about $1,100; at present, the system has about 90 mobile computers and a like number of scanners, she says.
As its pharmacy already has a system, about 80% of the meds could be bar coded there. "We had to get the other 20% bar coded and do it in a more efficient way," Sublett notes. "We outsourced it to another company, who came in with repackaging equipment." The equipment overwraps the existing packaging with a bar-coded label, she explains.
The system Our Lady of the Lake uses is from Cerner, Luttrell says. "You scan the wristband; it brings up the available meds to be given to that patient, so it has to be ordered in the system for that patient in order for it to show you can give it," she adds.
The facility currently uses laptop devices with tethered scanners, but over the next six weeks, it will go live with hand-held devices.
"We plan to deploy enough so each nurse will be able to use them to administer meds. In other words, we will have enough for the largest number of nurses on any scheduled shift," Luttrell adds.
Her team elected not to have a repackager at this point. "But we will do it shortly," she says. "We still felt so much safer, even though we don’t yet have all five rights being checked, which is what repackaging and being able to check all meds will do."
Luttrell’s team has found some errors with manufacturers’ codes, because they are applied by different companies, she notes. "Repackaging will put the same codes on all meds."
Bayshore uses a system it calls eMAR (medication administration record). "We used our existing clinical system, which was from Meditech," Harrigan says. "HCA [Bayshore is an HCA hospital] worked with Meditech because we have our own version [of Meditech], and developed a system capable for eMAR."
The system uses a bar-code technology that can scan the patient’s meds and bracelet with an electronic pen to verify or create the electronic signature.
"We used to send NCR copies in a tube system to the pharmacy," Harrigan says. "Now, when an order is written, with the bar-code scanner they scan the order to the pharmacy; it automatically pulls up on the PC, along with the patient’s Meditech number, so they know those two pieces go together.
"All our meds are bar coded," she continues. "We had about 80% of our meds already bar coded because we had McKesson’s robot system. We had to focus on the other 20%, which could be single-dose packages, multidose packages that would be broken into single doses, or liquids."
For the latter, Bayshore had to purchase what is called a "Wet Cadet," which bar codes liquid medications, Harrigan explains.
Change takes preparation
As with any major change, it took a great deal of preparation and staff training before these new systems could be implemented. The system that has been in place the longest is Danville’s, where an executive team including the CEO, the CIO, the information systems department, and the pharmacy made the decision to switch to bar coding in late 2001.
"The primary anticipated benefit was improved patient safety," Sublett recalls. "Human beings all make mistakes — such as poor handwriting — and you are depending on humans in the pharmacy to send you the right drug for the right patient."
All nurses had to go to a 3½-hour class to become proficient with the new system. "It was all taught by nurses, because they relate to each other better," she points out. "They learned it first, became our superusers, and then they taught others."
Danville’s performance improvement coordinator was involved in the implementation process. "Her specific role was to report to the quality council; we adjusted the design of the program as it was implemented," Sublett notes.
"We were a beta site, so her role was also to help assure that we met standards such as the Joint Commission on Accreditation of Healthcare Organizations, because she was most familiar with them, and also look at any policy changes we might have to make for medication administration. She was also the person who gave us the parameters we wanted to look at and set the benchmarks for data for each month," she says.
Danville benchmarked unit against unit, Sublett adds, and as improvement was achieved, the bar constantly would be adjusted.
Our Lady of the Lake ran a pilot program a couple of years ago and went housewide in December 2003. "We have a clinical leadership group that [planned the initiative]," says Luttrell, noting the group includes the vice president of nursing, the information systems department, the director of clinical information, and herself.
The pilot included two or three small groups. "We went through the pilot process, and it was a very quick learning experience," she recalls. "Then we were set in terms of what to do, so I conducted the [housewide] education."
Bayshore went live in June 2003. "This was part of HCA’s patient safety initiative," Harrigan explains. The implementation process took "a good six months," she says.
HCA corporate provided an implementation coordinator. "Fortunately, they had all the pre-assessment toolkits put together, with step-by-step information on conference calls, equipment set-up, training of staff, and so forth, that could be customized to each facility," Harrigan adds.
"The corporate person helped see that we were on track, that we had the right equipment ordered, that it was installed properly, and that all users were trained properly," she explains.
Apples and oranges?
It may prove difficult, sources say, to compare error rates pre- and post-bar coding, because the old and new systems are so different.
"In the paper world, you rely on nurses to submit the error; you don’t have that triplicate check system to get dose, time, medication, route, and patient," Harrigan explains. "With the electronic keys, you have all that — you scan the patient, you scan the med against what the pharmacy put in, and it will give you an error."
Comparing the two, she continues, "would be apples and oranges." With the electronic system, however, "You do find your near misses. And you have a reporting capability you never had before."
Luttrell agrees. "We don’t have data yet because we’re not checking the five Rs on all meds, so what we have would not be complete," she notes, "but we are gathering more reports of near misses, which I think is important."
"We are doing trending now of the percent of meds scanned by nurses, issues they have, the percent of bracelets scanned, and are working toward being at 90% for all of those," Harrigan explains. "Then we will be able to look and see if near misses are transcription errors from the pharmacy side or whether we need more education of the nursing staff, if the times of med administration need be adjusted, and so forth. You can look at all those pieces based on reporting — it’s an educational tool to see what processes you may have issues with."
Follow-up is essential
Ongoing follow-up is critical, Sublett adds. "Our medication safety committee meets once a month and reports our stats up to the quality council. If we get something wrong, then we need to improve even more."
For example, staff have learned they have to do a better job of regulating IV pumps, as the hospital has not yet purchased smart pumps, she says.
While such systems require a significant investment, Sublett stresses that hospitals cannot afford not to make the investment, regardless of size or budget.
"I think with the strong emphasis on patient safety, with patients being much sicker than they used to be, with higher turnover ratios, nurses and pharmacists need all the tools they can have to achieve better patient care," she asserts. "No matter the size of the facility, the investment is only going to improve your outcomes. It is costly, but so are medication errors; with what one negative outcome costs you, you could have had your system."
Luttrell agrees. "My opinion is that anything that makes it safer for your patients, no matter what the size of your facility, should be considered a priority."
Need More Information?
For more information, contact:
- René Harrigan, RN, Director IT&S and Communications, Bayshore Medical Center, 4000 Spencer Highway, Pasadena, TX 77504. Phone: (713) 359-2000. E-mail: [email protected].
- Nancy Luttrell, RN, MSN, Clinical Nurse Specialist, Neuroscience, Director, Nursing Informatics, Our Lady of the Lake Regional Medical Center, 5000 Hennessy Blvd., Baton Rouge, LA 70808. Phone: (225) 765-8113.
- Patsy Sublett, MSN, RN, BC, Clinical Systems Manager, Danville (VA) Regional Health System. Phone: (434) 799-2399. E-mail: [email protected].
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content