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. Marys Hospital Medical Center
• Russell Lewis
• Senior Vice President Chief Operating Officer
• Bridge Medical Inc.

2
Call To Arms
Approximately 98,000 Americans die each year from
medical errors . . . 7,000 of which are
medication errors

• Federal legislation
• State legislation
• Regulatory initiatives
• Purchaser incentives
• Consumer awareness

3
Where Do Medication Errors Occur?
12
39
11
38
(Leape LL et al. Systems analysis of adverse
drug events. JAMA 199527435-43.)
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

1 Barker, Flyn, Pepper, Bates, Mikeal 2002
5
Error Types
Medication Errors
Preventable events that lead to inappropriate med
use or cause patient harm
Adverse Drug Events (ADEs)
Preventable events that do harm patients
temporarily or permanently, including death
6
ADE/Hospital AdmissionMed Error/ADE Conversion
1 Classen et al 1997 4 Bates et al 1993 2 Jha et
al 1998 5 USP MedMARx 2000 3 Bates et al 1995 6
Bond et al 2001
7
Where Do Medication Errors Occur?
12
39
11
38
(Leape LL et al. Systems analysis of adverse
drug events. JAMA 199527435-43.)
8
Intercepting Medication Errors
Prescribing Transcribing
Dispensing Administering
Medication Phase Error Distribution
39
12
38
11
Per 100 Errors
39
12
11
38
Intercept Rate
48
33
34
2
Errors Reaching Patient
20
8
7
37
True Error Rate
22
11
10
51
Adapted from Leape et al, 1995 and California
Healthcare Foundation, 2001
9
Barcode Proponents

• T. Thompson, Secy 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
ADT
BPOC System
Bedside Barcode Unit
Pharmacy
Reporting Error Analysis
Billing
Other Clinical Systems
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?
12
39
11
38
(Leape LL et al. Systems analysis of adverse
drug events. JAMA 199527435-43.)
18
Violation of 5 Rights
18.6
33.9
23
1.3
15.1
2.9
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

• JCAHO 1998
• 1 ADE costs 2,000 (excluding malpractice)

• Jury Verdict Research
• Average malpractice award for a medication error
  is 636,000

• CA HealthCare Foundation
• Preventable ADE costs 5,000
• 6.5 of all hospital admissions result in ADE

• Leapfrog 2001
• 1 med error costs 10
• 1 ADE costs 2,000

• Schneider 1995
• Med error requiring extra lab or treatment costs
  95 to 227
• Med error prolonging length of stay costs 2,596
• Med error resulting in near-death experience
  costs 2,640

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
• PT
• 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)

• Staff scan barcode on name badge, enter secure
  password
• Scan Barcode on patient ID to access patients
  MAR
• Scan Barcode on unit-dose medication
• Verifies 5 Rights provides alerts

33
MedPointTM
Pharmacy order to MedPointTM via radio frequency
34
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35
Scan the barcode on the patients wristband to
access the ordered medications.
36
When there are orders that need to be confirmed,
the Ordersscreen will present immediately after
identifying the patient.
Order states Active, Discontinued, Future, Hold
Resume, Invalid
Med Name, dose, route, frequency and comments
display
37
Bedside MAR
38
Warning Message Definitions
Alert Look a like / sound alike. Medication
may have similar name
39
Warning Message Algorithm
Nurse Response
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, 0859, 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
  patients 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.

44
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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

• Post-Implementation
• Automated MAR
• Electronic documentation
• Real time documentation
• Reduced reliance on memory
• Legible documentation
• Documentation available in one place
• Automated recording of near misses/errors

47
Nursing Workflow Benefits

• Automates worksheets, documentation
• Eliminates nightly MAR reconciliation
• Clarifies orders
• On-line reference

48
Medication Incident Rate
July 2001-2002
data source incident reports from 34 bed nursing
unit
2

• 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)

1
0
Sep
Nov
Mar
May
1-Jul
2-Jan
Nov 01 mandatory eMAR use
49
Recurring Meds with Warnings
July 2001
Med Respons. Warnings Adm Cx NG
Nebs Respiratory 118 86 32 0 6.4 BS
Testing Nursing 115 81 31 4 6.2 Insulin Nursing 1
08 69 29 9 5.8 NS Flush Nursing 74 48 21 4 4.0 Cef
azolin Nursing 44 31 10 2 2.4
NAHQ 2001
50
Summary data
Reasons for Late Doses, all units
3
No reason
3
See RT note
Route inaccessible
7
Physician order
16
Staggered dosing times
21
Given on arrival
30
Patient asleep
49
69
Patient request
Med not available
121
135
Patient condition
177
Patient off unit
Given earlier
493
Other
728
Backtime order
2591
0
500
1000
1500
2000
2500
3000
51
Data Analysis
52
Warning Summary Detail Report
53
Near Miss Detail

• RN selected order number XXXX for atenolol 25mg
  oral q am via ordered med on 01/18/02 at 1725
  and received this warning Order discontinued as
  of 01/18/02 at 1501. 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

• Protecting my patients and my license.

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 Didnt 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?