Course Objectives • Evaluate the current barcode symbology used in health care for positive patient and medication identification in a healthcare environment. • Develop bedside medication metrics to maximize patient safety benefits. • Recommend a strategy to prepare your caregivers for known workflow workarounds that impede the effective use of bedside medication scanning systems. Develop strategies to avoid common pitfalls. • Compare and contrast how different mobile technology platforms will impact nursing workflows with the implementation of bedside medication scanning. • Propose strategies for IT and nursing to work effectively to assist both nurses and care teams to cross the clinical communication chasm. • Justify adjusting daily workflow processes for pharmacy and nursing when using centralized bar code distribution technology to support bedside verification. Evaluate the effects on patient safety. • Propose a strategy to prepare ambulatory setting for BCMA implementation.
Bar Code Technololgy • A bar code is a machine readable graphical representation of a number or other character string. • A bar code reader translates that string and transmits the data to the computer system. • The computer interprets that data as keyboard input so scanning occurs at a set point in the routine. • There are three basic types of bar code readers: fixed, portable batch, and portable RF1. It’s important to pick one that best fits your need. 1 http://www.barcodehq.com/primer.html#READERS (Not an endorsement for any product advertised on that website)
Bar Codes and Bar Code Readers • 1D Bar Codes • Come on most packages • 2D Bar Codes • Becoming more popular on UD packaging • Fixed readers • Connected to PC (USB recommended) • COWs • Portable Batch • Portable RF • Recommend for Isolation rooms
Bar-Coding Everything • Buy products that are already bar-coded by the manufacturer: • Including liquids, topicals, injectables • Items not commercially available with manufacturer barcodes they need to be bar-coded locally. • Bar codes can be printed on different types of printers, depending on the software.
Bar-Coding Everything “The U.S. Veterans Health Administration has announced that it prefers its 173 hospitals, when purchasing medications, to purchase those whose unit doses have been labeled with bar codes. Similar messages by other large healthcare systems should provide a major competitive incentive for manufacturers to accelerate the investments and develop the production lines that packaging unit doses of medications with bar codes will require.” Drug Topics, “How pharmacy technology has evolved: what is and what could be,” March 19, 2007
Recommendations • Purchase 2D readers: • USB preferred over keyboard interface • Portable RF good for isolation (put in a bag to take in and scan patient wristband then do the rest in the hallway) • Get a maintenance agreement because they will get dropped and broken. • Buy a few extra readers and keep them ready (ie. RF units charged) so work can go on while units are in for service. • Put a “technie nurse” in charge of the equipment, not an IT person. • Develop a QA process that includes periodic equipment checks.
Why BCMA Barcode medication administration (BCMA) and electronic medication administration record (eMAR) technologies are two ways to improve inpatient medication safety by automating the process of medication checking, and making the medication administration record electronic. Research has demonstrated successful reductions in the rate of medication administration and dispensing errors after the implementation of barcoding systems, especially when the barcodes are affixed to medications at the level of the unit-dose. Hook JM, Pearlstein J, et al. Using Barcode Medication Administration to Improve Quality and Safety. AHRQ Publication No. 09-0023-EF Dec 2008; 1.http://healthit.ahrq.gov/images/dec08bcmareport/bcma_issue_paper.htm Accessed 6/29/2011
What is BCMA? • Bar Code Medication Administration • BCMA is a separate GUI application (not part of EHR) used to administer medications
How does BCMA work? • BCMA allows users to electronically document medications at the bedside or other points-of-care. • The nurse will have a medication cart equipped with a wireless laptop and a barcode scanner.
BCMA • BCMA is used to record administration of medications. • But it also provides functions such as: • Meds Due List • Variance Log (e.g. med errors) • Med Admin History • PRN Effectiveness tracking • Missed Medications • Request missing Med from Pharmacy
BCMA and Administration Schedules • BCMA doesn’t handle ambiguity. • Schedule ranges need to be removed (i.e. Q4-6H PRN needs to become Q4H PRN). • Standard schedules must have defined admin times, e.g.: • Q4H 0100-0500-0900-1300-1700-2100
BCMA • All “versions” of a medication must be scanned into Inpatient Pharmacy as a synonym for it to be recognized by BCMA. • BCMA can use IENs or other standard identifiers such as NDC numbers.
IVs vs. IV Piggybacks • A frequent area of confusion is configuration of IV Piggybacks so that they will function correctly in BCMA.
IVs vs. IV Piggybacks • IV Piggybacks are Unit Dose with a Route of IV and a Schedule (e.g. Q6H) • IVs are Large Volume and Continuous with an Infusion Rate (e.g. 75ml/hr)
When is a med due? • With standard BCMA configuration a medication is due the next scheduled administration time. • It is important that everyone be trained to understand this. • This will sometimes necessitate using the ‘First Dose Now’ button to start the medication as desired by the Provider.
BCMA and Order Verification • Using BCMA properly, nurses should never Verify (in EHR) a Pending medication. • Verification should only happen after Pharmacy has completed the order. • The med nurse should never administer a med that has not been Completed by Pharmacy and Verified by Nursing.
Admin Process • The basic process of passing medication remains the same. (BCMA is not a substitute for Nursing Judgment. • This includes: • Wrist band (now with Bar Code) • Identity verification (i.e. ask pt’s name) • Right Drug • Right Dose • Right Route • Right Time
Common Workarounds • Causes • “Fat cows grazing in the hall”2 • When asked to describe factors that limited the impact of the BCMA system effectiveness, responses included "technical problems," including bar codes that did not scan and reliability of the computer equipment, as well as medication administration scheduling control by the clinical pharmacists who entered those data into the system.3 2Comak, H. Fat COWs ‘grazing’ in hall lead to BCMA workarounds, HCPro Patient Safety Monitor Blog, Feb 18, 2010. http://blogs.hcpro.com/patientsafety/2010/02/fat-cows-grazing-in-hall-lead-to-bcma-workarounds/ Accessed 7/7/2011 3 Morris F, et al, "Nurses Don't Hate Change" - Survey of nurses in a neonatal intensive care unit regarding the implementation, use and effectiveness of a bar code medication administration system, Healthcare Quarterly, 12(Sp) 2009: 135-140 accessed 7/7/2011
Dangers of Workarounds • Wrong patient • Wrong drug • Wrong time • Wrong dose • Poor accountability • Poor documentation • Increased patient risk • Increased risk to the facility
Other References • Mary V. Wideman, et al, Barcode Medication Administration: Lessons Learned from an Intensive Care Unit Implementation. Accessed online. www.ahrq.gov/downloads/pub/advances/vol3/wideman.pdf • Koppel R, et al, Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety. J Am Med Inform Assoc. 2008 Jul-Aug;15(4):408-23. Epub 2008 Apr 24. http://www.ncbi.nlm.nih.gov/pubmed/18436903 • Agrawal A, Glasser AR, Barcode medication. Administration implementation in an acute care hospital and lessons learned. J Healthc Inf Manag. 2009 Fall;23(4):24-9. http://www.ncbi.nlm.nih.gov/pubmed/19894483