Transcript PUTTING PATIENTS FIRST eMAR/Bar Coding Technology

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
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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-MAR
Electronic Medication Administration
Record
Every Med administered Right!
(HCA, 2001)
BCMA
Bar 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
90.00%
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
Level 1
Level 2
Level 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.
Relationship of Adverse Drug Event, Adverse Drug Reaction and Error
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
Med Errors
Level 1
errors
ADEs
and
ADRs
(error)
Potential
ADEs/ADRs
ADEs
and
ADRs
(no error)
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.
These are injuries or reactions
that were not related to error
and were non-preventable
Level 2-3 errors
-0
2
2
03
-0
2
2
2
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-0
n-
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ep
Ja
N
S
1
1
02
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ar
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M
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1
1
1
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Ja
N
S
0
0
01
l- 0
ay
ar
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M
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-0
0
0
0
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Ja
# per 100 A PD
“Reported” Med Errors per 100
Adjusted Patient days
Reported M ed Errors through HNS
(Including near m isses)
1.2
1
0.8
0.6
0.4
0.2
0
Errors resulting in ADEs:
Harvard Study
6%
eMAR &
Barcoding
34%
4%
ePOM*
56%
Ordering
Administration
Transcription
Dispensing
* Electronic physician order
management
Bates DW et al. Incidence of adverse drug events and potential adverse
drug events. JAMA 1995;274:29-34.
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.
With
Implementation
2.
3.
Increase in REPORTED
medication errors related to
medication administration
Decrease in medication errors
related to medication
administration that reach
patients.
Increase in “near miss”
medication errors related to
medication administration.
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 Will obtain facility go
Bar Coding technology live rate and unit go
will have an increase in live rate.
overall reported
medication errors as
compared to units
without the technology
within the same
hospital.
Measuring the impact of eMAR and
Bar Coding Technology, continued
Medication errors Expected Outcome
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.
2.
Increase in reported med
errors related to med
administration particularly
the five rights of med
administration.
Reduction in med errors
that reach the patient
related to med
administration particularly
the five rights of med
administration
Tentative
Timeline
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
Bedside
Scanning
Electronic
Safety
Checking
Barcoded
Medication
Doses
Electronic
Medication
Administration
Record
HCA 2001
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
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
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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
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Leape, Lucien L., et al. System Analysis of Adverse Drug
Events. Journal of the American Medical Association, 274, 1995.
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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.
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Nadzam, Deborah M. Development of medications use
indications by the Joint Commission on Accreditation of Healthcare
Organizations. AJHP. 48:1925-1930, 1991.
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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
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Low, Deborah K., Belcher, Jan V. Reporting medication errors
through computerized medication administration. Computers
Informatics Nursing. Pp 178-183, September/October 2002.
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Neergard, L. Hospital devising new ideas to cut medical errors.
Available at: http://www.nandomtimes.com. Accessed April 28, 2003.
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Sarudi-Scalese, Dagmara. Medication Safety Bar Coding: The
Forgotten Technology. Hospital and Health Networks. April 2002.
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Bar Code Medication Administration Tech Knowledge. Volume
I, Issue 5. June 2002. Pharmacy Healthcare Solution.
http://www.mederrors.com
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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.
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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)
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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.
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Johnson, C., et al.,Journal of Healthcare Information
Management. December 2001.