Implementation of an Electronic Medication Administration Record using

Bar Code Technology

A collaborative project between Pharmacy, Nursing, Respiratory Care and Information Systems.

Presented by Sue Ebertowski

• A licensed 760 bed facility

• 442 beds are considered operational

• Tertiary care facility

• Owned by HCA-the Healthcare Company

• Level 1 Trauma Center

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.

Background, continued

• WMC is located within a community where Boeing has a large employee base. Boeing’s involvement with Leapfrog and WMC’s 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.

E-MARElectronic Medication Administration

RecordEvery Med administered Right!

(HCA, 2001)

BCMABar Coded Medication

Administration

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)

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)

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)

Types of medication errors at WMC

0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%

Level 1Level 2Level 3

• 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

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.

Potential ADEs/ADRs

ADEs and

ADRs (error) ADEs

and ADRs

(no error)

Med Errors Level 1 errors

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

These are injuries or reactions that were not related to error and were non-preventable Level 2-3 errors

SLOW

These are “near misses,” or errors caught before reaching patient

Adapted from Bates DW et al. J Gen Intern Med 1995; 10:199-205.

Relationship of Adverse Drug Event, Adverse Drug Reaction and Error

“Reported” Med Errors per 100 Adjusted Patient days

Reported Med Errors through HNS (Including near misses)

0

0.2

0.4

0.6

0.8

1

1.2

Jan-99

Mar-99

May-99

Jul-99

Sep-99

Nov-99

Jan-00

Mar-00

May-00

Jul-00

Sep-00

Nov-00

Jan-01

Mar-01

May-01

Jul-01

Sep-01

Nov-01

Jan-02

Mar-02

May-02

Jul-02

Sep-02

Nov-02

Jan-03

# p

er

10

0 A

PD

56%34%

6% 4%

OrderingAdministrationTranscriptionDispensing

Errors resulting in ADEs: Errors resulting in ADEs: Harvard StudyHarvard Study

Bates DW et al. Incidence of adverse drug events and potential adverse drug events. JAMA 1995;274:29-34.

eMAR & Barcoding

ePOM*

* Electronic physician order management

Related Research

• Veterans Administration Hospitals have 10 years of history with Bar Coded Medication Administration.

• Colmery-O’Neill 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)

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.

Measuring the impact of eMAR and Bar Coding Technology

Measurement Expected outcome Tentative Timeline

Medication Errors

1. Increase in REPORTED medication errors related to medication administration

2. Decrease in medication errors related to medication administration that reach patients.

3. Increase in “near miss” medication errors related to medication administration.

With Implementation

Measuring the impact of eMAR and Bar Coding Technology, continued

Measurement Expected Outcome Tentative Timeline

Reported unit medication rate compared to overall hospital reported medication error rate

Units with eMAR and Bar Coding technology will have an increase in overall reported medication errors as compared to units without the technology within the same hospital.

Will obtain facility go live rate and unit go live rate.

Measuring the impact of eMAR and Bar Coding Technology, continued

Medication errors Expected Outcome

Tentative Timeline

Percentage of reported med errors due to dose omission, improper dose, wrong med, wrong route, wrong patient, monitoring error

Percentage of reported med errors classified as “near misses”

1. Increase in reported med errors related to med administration particularly the five rights of med administration.

2. Reduction in med errors that reach the patient related to med administration particularly the five rights of med administration

With implementation

Measuring the impact of eMAR and Bar Coding Technology, continued

Measurement Expected Outcome Tentative Timeline

Perception and proficiency of Pharmacy, Nursing, and Respiratory Therapy Staff

Realignment of nursing and pharmacy tasks will not result in increased time spent on the medication process

Evaluation by each unit within 3 months of going live

Nurses and therapists continue to use the scanning features of the system 3 months after implementation

Staff will find the EMAR and Bar Coding technology useful in creating a safer care environment for patients.

Evaluation by each unit within 3 months of going live.

eMAR/Bar Coding Is . . .

Barcoded Patient Armbands

Barcoded Medication Doses

Electronic Safety Checking

Electronic Medication Administration Record HCA 2001

Bedside Scanning

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)

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 nurse’s inability to view a chart that a physician is viewing.

• BCMA allows RN’s to order refills at the push of a button, eliminating phone calls and paperwork. (Patterson, E. et.al 1995)

Unintended side effects of BCMA

• During busy periods, RN’s 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.

Unintended continued

• RN’s became nervous when required to type an explanations for late meds.

• System’s 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.)

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.

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)

electronic MAR & Bar coding

Implementing eMAR/Bar Coding

Prerequisites

Equipment

Decisions

Budget

Considerations

Staff

Resources

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.

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.

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.

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

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.

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.

Progress Thus Far!

New Storage Needs

• All meds bought in bulk and repackaged

• Increased storage needs.

New Packaging

• Multiple meds stored alphabetically in drawers in carousel

Examples of Bar Codes for different type drugs

The Fluids “Packer”

• All liquids bought in bulk.

• All liquids packed, labeled and bar coded by “packer”.

One of the Pill “Packers”

• Bulk pills packaged by pill packer.

• Medication labels generated with the aid of the computer

• 3000 doses per hour

The Nurse’s “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

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

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.

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.

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., 324:370-376, 1991.

• Nadzam, Deborah M. Development of medications use indications by the Joint Commission on Accreditation of Healthcare Organizations. AJHP. 48:1925-1930, 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.

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.nandomtimes.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.mederrors.com

• Johnson, Connie L., Carlson, Russell A., Tucker, Chris L., Willlette, Condore. Using BCMA software to improve patient safety in Veterans Administration Medical Center.

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.