The Impact of Barcode Point-of-Care Technology on Patient Safety

1. The Impact of Barcode Point-of-Care Technology on Patient Safety Sherry Anderson RN, BSN Director Float Pool, Internal Quality Improvement Consultant St. Mary�s Hospital Medical Center & Russell Lewis Senior Vice President &Chief Operating Officer Bridge Medical Inc.

2. �Call To Arms� Federal legislation State legislation Regulatory initiatives Purchaser incentives Consumer awareness

3. Where Do Medication Errors Occur?

4. Frequency of medication errors Archives of Internal Medicine, Vol. 162, SEP 9, 2002 Random sample of 36 institutions Direct observation Narrow definition of error Potential ADE rate determined by 3-physician advisory panel Conclusions: Medication errors are common, 19% 1 out of every 5 doses ! 7% of all errors were rated as potentially harmful 40 ADE per day in a typical 300 patient facility

5. Error Types

6. ADE/Hospital AdmissionMed Error/ADE Conversion

7. Where Do Medication Errors Occur?

8. Intercepting Medication Errors

9. Barcode Proponents T. Thompson, Sec�y Health and Human Services American Society of Health-System Pharmacists National Coordinating Council of Medication Error Reporting and Prevention Institute for Safe Medication Practices FDA

10. Barcoding at the Point-of-Care 91% of US hospitals use computers to process medication prescriptions Less than 13-15% of all US hospitals use computers for initiating medication prescriptions Few US hospitals use barcoding to verify the right patient is receiving the right drug

11. Barcode Medication Administration Technology Nurse barcode scans name tag Nurse barcode scans patient identification bracelet Patient MAR appears on bedside laptop or hand-held device Scheduled and PRN meds are scanned Warnings/alerts are issued when indicated Automatic documentation of administration activities

12. Barcode Technology Series of vertical lines and spaces that scanner converts to electrical signal understood by computer Used in grocery stores since 1970s Can store alpha and numeric and information Provides accurate, fast, real-time data collection and entry Offers exceptional security Minimizes errors associated with manual data entry

13. Percent Medications Barcoded by Manufacture Approximately 30% of all manufactured drugs are identified with a barcode FDA is taking steps to mandate barcoding With analysis of high use meds, can barcode to maximize barcode scannable administrations (85%-90%) Automation and service based packaging and barcode labeling solutions

14. BPOC Information Flow

15. Barcoding at the Point-of-Care Medication Administration Transfusion Error Checking Specimen Collection Supply and Procedure Charge Capture

16. St. Marys Hospital Medical Center 350 beds Level II tertiary care center Shared Governance Nursing model Continuous Quality Improvement (CQI) culture Magnet Nursing Services Recognition Award for Acute Care Nursing Service

17. Where Do Medication Errors Occur?

18. Violation of �5 Rights�

19. Our Experience 60% of our reported errors were in the administration part of the process Previous changes had not had an impact on the error rate Knew technology had to be our next step for improvement Developed proposal and received approval to partner in this project

20. Cost of Errors

21. Information Technology Solutions

22. Improvement Focus Identified previous process improvement changes Identified gaps in achieving additional improvement Defined technology solution to provide a safety net at the bedside Real time information Accurate, consistent documentation Enhanced pain management Billing accuracy

23. Levels of BPOC

24. Bar-Coding Solves the Problem Provides safety net at the bedside Intercepts medication errors Automatically documents Automates error reporting Integrated with nursing work flow and complementary to existing clinical applications

25. Implementing Barcode enabled Point of Care (BPOC) Interdisciplinary approach Identify linkages Administrative Council Risk Management P&T QI Council Practice Council Identify key customers/stakeholders Establish a team

26. Departments Affected Departments affected by changes in the medication process Pharmacy Nursing Medical Staff Information Technology Business Office Clinical Engineering Housekeeping Plant Human Resources Telecommunications

27. Implement for Success Clinical champions Strong management support Physician champion Timely response to concerns, questions Constant, daily communication Identify measurements of success before implementation begins Dedicated IT support

28. Goals and Expectations(Hospital Wide) Automatic recording of errors/near misses 50% decrease medication incidents 50% decrease in near misses Eliminate duplicate charting Simplified/accurate billing process Easier physician access to information Quick quality check for trends Knowledge enhancement with immediate feedback

29. Our Technology Solution Barcode enabled, wireless, touch screen computer Software checks to assure 5 rights are met Warning screens prompt the nurse Online order verification Work sheet Real time, electronic documentation

30. Identify Barcode Needs Look at internal systems first Identify which medications get to the patient Can the systems providing those labels support bar-coding? Can the systems support a patient-specific barcode, patient account number and order number? Can the systems support the NDC bar code?

31. Address Barcode Needs in Your Organization Identify medications already bar-coded by the manufacturer Determine which medications pharmacy produces that are patient specific Evaluate the ability of existing pharmacy system printers to add barcode to labels Establish process to verify medications against your formulary Create Patient ID bracelets with barcodes Develop Employee ID badges with barcodes

32. Barcoding at the Point-of-Care(BPOC)

33. MedPointTM

37. Bedside MAR

38. Warning Message Definitions Twelve warning messages may be generated during medication administration. These are: dose omitted, early, late, and duplicate med; max dose reached, no order, order d/c, order expired, wrong route, wrong range, wrong single dose value, and future dose.Twelve warning messages may be generated during medication administration. These are: dose omitted, early, late, and duplicate med; max dose reached, no order, order d/c, order expired, wrong route, wrong range, wrong single dose value, and future dose.

39. Warning Message Algorithm

40. Clinical Example A patient had an order for Glyburide (Diabeta) 5 mg by mouth every day The nurse scanned the barcode on what she thought was Glyburide The following warning appeared:

41. Clinical Example Upon closer inspection what she had scanned was Glipizide (Glucotrol) Pharmacy had dispensed Glipizide instead of Glyburide Besides being from the same classification, these two generic drugs have similar sounding names and nearly identical packaging.

42. �Barcode Order Not For Patient� November 13, 2001, 08:59, Room 301-A The nurse barcoded �Dalteparin Sodium� and received warning: �Barcode Order Not for Patient.� The Nurse cancelled transaction. No other attempts to give this med over course of patient�s hospital stay. Of interest, on same day, same nurse administered Dalteparin Sodium, without this warning, to a patient in Room 303-B.

43. �Order Discontinued� October 22, 2001, Room 652-B The nurse selected �Warfarin Sodium 5 mg� and received warning: �Order discontinued�. The Nurse cancelled the transaction. November 5, 2001, Room 631-A The nurse selected �Potassium Chloride (K-Dur SR tab) 20 mEq� and received warning: �Order discontinued�. The Nurse cancelled the transaction.

45. Automates Documentation

46. Pre and Post Implementation Comparison Pre-Implementation Incomplete MAR verification Manual MAR entries Inaccurate documentation Incomplete charting Limited allergy information Physician access to information complicated Voluntary reporting

47. Nursing Workflow Benefits Automates worksheets, documentation Eliminates nightly MAR reconciliation Clarifies orders On-line reference

48. 59% decrease in errors in 6 months Nurses administer average 18000 doses per month on one nursing unit 500 times per month they heed the warning messages & cancel out (3% near miss rate) Medication Incident Rate

49. Recurring Meds with Warnings

50. Summary data

51. Data Analysis

53. Near Miss Detail RN selected order number XXXX for atenolol 25mg oral q am via ordered med on 01/18/02 at 17:25 and received this warning: Order discontinued as of 01/18/02 at 15:01. The user then cancelled and there were no further administrations of this med within the next 60 minutes.

54. Resources Nursing 1.0 fte RN Information Technology 1.5 fte Pharmacy .5 fte pharmacy tech .5 - 1.0 fte pharmacist

55. Nurse Satisfaction Recruitment & retention tool Positive nursing surveys �BPOC moments�

56. Does The System Provide Added Safety That Is Important To You?

57. Additional Benefits Charging at administration/phlebotomy Avoids Medicare fraud/abuse liability Assists meeting regulatory standards Feeds inventory management

58. What Didn�t Work Housekeeping support Information Services support Missed key pharmacy member

59. Current Status Operational on 3 Med-Surg Units and the Neuro ICU Expanding to adult Med-Surg and ICU beds in 2002 Requested capital dollars to expand to Peds, Psych and other specialty units in 2003

60. Summary Major change for Pharmacy and Nursing The point of care system has provided the desired error reductions Next Steps Expand and refine the system Bar code remaining medications Utilize data to implement changes Blood bank, specimen and billing

61. �Any effort to decrease medication errors must be interdisciplinary and include grass roots clinicians � those who do the day to day work of giving medications to patients.� Sherry Anderson RN, BSN

62. Questions?