October 26, 2009

Crush Medication Errors
By Alice Shepherd
For The Record
Vol. 21 No. 20 P. 20

The successful implementation of medication bar-coding technology requires a series of critical decisions backed by the support and cooperation of several key hospital departments.

Although the FDA requires drug manufacturers, repackers, relabelers, and private-label distributors to include linear bar codes on the labels of certain human drug and biological products, the use of bar coding in hospital medication administration is currently not legislated. However, because The Joint Commission asks for two patient identifiers in medication administration, about 20% of hospitals have implemented bar coding to facilitate patient identification and prevent medical errors. Yet only about 5% of those hospitals use bar-coded medication administration in all their units.

Providence Health & Services in Oregon and Children’s Medical Center Dallas, both of which were among the early adopters of bar-coded medication administration, encountered several challenges on the path toward successful implementation.

The basics of bar coding are simple: The clinical information system generates bar codes that are printed on a patient’s armband upon admittance. Before a drug is administered, its bar code and the bar code on the armband are read and matched up according to the physician’s order. The record is then updated to reflect the medication administration.
Preparing to implement that seemingly simple process, however, is quite a bit more complex.

“The prerequisites for bar-coded medication administration are an order communication system and a pharmacy system already in place,” says Ned Simpson, LFHIMSS, principal of CSC Global Health and coeditor of HIMSS’ Implementation Guide to Bar Coding and Auto-ID in Healthcare: Improving Quality and Patient Safety. “Ideally, a facilitywide Wi-Fi network should also be in place that reaches all sides of the bedside.” Simpson has observed that some hospitals only have Wi-Fi in the corridors, which may not even reach the bedside closest to the corridor.

“The wireless network should enable physicians and clinicians to go from location to location and floor to floor, remaining logged on without ever dropping the connection,” says Bruce Douglas, FHIMSS, project manager at Providence Health & Services. “The network infrastructure has to support not only the handheld devices used for reading bar codes but also the many other wireless devices deployed within the organization,” adds Debra Schumann, RN, BSN, MBA, director of clinical informatics at Children’s Medical Center Dallas.

Like any technology deployment, bar coding requires executive support, including the blessing of the chief financial officer and the chief nursing officer. “Expect a long, expensive implementation,” says Schumann. “Step one is to develop a mechanism for bar coding your medications and to select a system that meets your organization’s needs.”

Douglas recommends using a phased approach to implementation. “Start with the easiest one, medical-surgical, and then proceed to more unique and challenging areas one at a time, such as behavioral health, OB [obstetrics], and critical care,” he says. “Whenever you tackle one of those specialty areas, your project team needs to include people who work there—nurses, not nurse managers.”

Children’s Medical Center spent about three months on design, nine months on the building process (including a concurrent pharmacy build), three months on testing, and one month on training. “This was the vendor’s first pediatric hospital,” says Schumann. “With other organizations that don’t repackage their medications the way we do, vendors can be more nimble and plug and play using manufacturers’ bar codes.” Children’s Medical worked closely with its vendor to develop the specific two-dimensional bar codes it needed for easy, accurate scanning of pediatric doses of medication.

As far as “equipment” goes, a critical decision must be made whether to purchase bar-code scanners or imagers. “Both fall under the genre of readers,” Douglas explains. “Scanners are an older technology that only reads linear bar codes easily. Scanners can read stacked and composite bar codes often but not two-dimensional bar codes, whose use is increasing in the medical industry.”

Bar-Code Dynamics
A stacked bar code is algorithmically divided into a top and bottom section to place on labels that are too short to accommodate a long, linear bar code. Composite bar codes are composites of several different bar-code symbologies, and two-dimensional bar codes are the type that looks like a tiny road map shrunk down to a quarter-inch square. “Although the FDA requires that pharmacy industry products contain linear bar codes, many products, such as tiny vials, cannot accommodate them,” says Douglas. “If a facility chooses to purchase bar-code scanners rather than imagers, it had better be prepared to have its pharmacy re-bar code many products so they can successfully be scanned at the bedside.”

 Another decision must be made regarding tethered vs. wireless bar-code imagers. “Imagers tethered to PCs are inconvenient because they have to be dragged across the room and the patient’s bed to scan the armband,” says Douglas. “That’s not a patient satisfier.” He also recommends purchasing computers for every room rather than relying entirely on computers on wheels (COWs). “It’s more practical to have computers in every room with bar-code imagers,” he says. “COWs have to be staged somewhere while not in use, and they can’t be in hallways because of fire marshals’ restrictions. They’re going to be in some alcove, and pulling them back and forth for an eight-hour shift is a very tough job.”

However, Douglas observes that a few COWs are still a necessary investment for backup when computers go down and for use by therapists, dietitians, or pastors while nurses work on the computer.

 Simpson has consulted with hospitals that tried both COWs and handheld computers. “Some staff strongly disliked handhelds and loved COWs; others thought handhelds were perfect and couldn’t tolerate COWs,” he says. “Preferences also change over time. It takes a while to get used to the handhelds, particularly because of the battery recharging issue.”

For patient armbands, Douglas recommends direct thermal printing rather than thermal transfer. “Direct thermal burns an image onto a heat-sensitive armband,” he explains. “Thermal transfer requires the use of single-pass ribbons, which are frustrating to reload and need to be disposed of properly because they retain protected health information.”

Douglas also suggests purchasing armband printers that can be switched to manual operation during system downtimes. Admitting staff can continue to issue armbands, and bar-coded medication administration can proceed as long as the pharmacy and nursing systems are still running. In manual mode, the staff member responds to prompts on the printer and enters the patient’s name, age, date of birth, account number, medical record number, and other information using a keyboard attached to the printer to create the armband.

Another potential problem is the positioning of the bar codes. As armbands wrap around patients’ wrists, the bar codes are usually distorted and difficult to read. For this reason, Douglas recommends printing shorter bar codes across the armband rather than lengthwise. “Eleven-digit bar codes are about three quarters of an inch long, so they fit across the armband without distortion,” he explains. “You can now print it three or four times around the armband to make it easy to find.” He suggests testing bar-coded armbands by washing them under hot, soapy water and wiping them with an alcohol swab. “Bar codes on patient armbands should last for at least a week,” he says.

Avoiding Culture Shock
HIMSS recommends that bedside bar-code administration precede computerized physician order entry implementation, but it all depends on the organization, says Simpson. “Bar-code bedside administration is a much smaller, less expensive project, which does not require a huge behavioral change on the part of physicians,” he explains. “It might require some new processes to ensure consistency and standardization across units of clinical and administrative activities, but it’s a smaller scale and more manageable project. However, vendors will usually encourage organizations to begin with the bigger project, and health systems, too, may more readily rally around a bigger project.”

Children’s bar-coded medication administration system has been in use for every single inpatient since 2006, when the hospital went live with all of its intensive care units. “We recently converted to our third bar-coded medication system (Epic), which includes bar coding in a totally integrated EHR solution,” says Schumann. “The first time we implemented bar coding, it was driven by the pharmacy but developed with both nurse leaders and pharmacists around the table. With our second implementation, we brought frontline nurses into the IT department on a biweekly basis to guide the process. For our third implementation, an advisory committee of senior nursing directors nominated staff nurses and respiratory therapists who participated throughout the design and development phases.”

“The implementation needs a tenacious nursing supporter for the first year or two who can, on a daily basis, review reports and ensure that every medication administration is being scanned and, if not, determine if it’s a training or configuration problem,” says Simpson. “The nursing supporter has to promote the system’s use every day, continuously streamlining and tuning it to ensure its full application.”

Involving nurses early in design and testing usually ensures greater end-user acceptance. For example, Children’s Medical Center took COWs and handheld devices on “road shows” from unit to unit. “Our handheld devices were selected by the staff,” says Schumann. “We let them try several alternatives, and they voted on which ones would best meet their needs. The nurses love the technology and no longer want to give meds without it.”

“There is generally a vocal nurse who doesn’t like the idea of bar-coded medication administration initially,” says Simpson. “[However,] as soon as the system issues a warning that someone was about to make a mistake, it results in a conversion and turns critics into advocates.”

A healthy dose of training can also go a long way toward easing transition. “Training is a huge factor, and you can never have enough of it,” says Douglas. “Nurses need to understand they will have to provide reasons for not giving a medication, overriding an alert, or administering a drug without an order. Training has to cover both technology and changes to workflow.” He recommends that all training be conducted by nursing trainers, not IT people who usually don’t understand nursing workflow. Policies and procedures documenting the new workflow are also essential. Finally, medication administration schedules need to be aligned across all units so that patients who transfer receive their doses consistently wherever they are. At Children’s Medical, classroom training for mobile meds and clinical documentation added up to about 24 hours per nurse.

Despite training, it’s always tempting to take shortcuts, such as scanning a chart label instead of the patient’s armband when the patient is sleeping. Douglas has a solution. “The bar code on the armband should be unique and different from any other bar code you are generating in your health system,” he explains. “We include an extra character in the bar code on the armband.”

Pharmacy Support
As a pediatric institution, Children’s Medical Center has to repackage most of its bulk medications for distribution to the small patients, which necessitates the creation of custom bar codes. “Our pharmacists enter orders into the pharmacy system, which then produces patient-level labels for the drugs,” says Schumann.

“Every product that comes out of the pharmacy has to have a bar-coded identifier on it,” says Douglas. “With unit dose oral solids, that’s typically the NDC [National Drug Code]. However, for IVs, there may be one NDC for the bag of solution and another for the products that are added to it. Therefore, many pharmacy systems use a unique identifier that typically relates back to the order.”

Another complication resulting in extra pharmacy work is that many products arrive with two manufacturers’ bar codes. For example, there may be one identifying a box as containing 48 vials of insulin, with another identifying the individual product in the box. It is the latter that has to be read for medication administration. “The pharmacy will need the ability to generate bar codes and apply them to items that either don’t have a bar code or have one that is not recognized by the scanners,” says Douglas. “Further, if your pharmacy system is not integrated with your nursing system, it requires a great deal of extra work in the pharmacy to make sure its system feeds across and is recognized and visible in the clinical system. The two systems have to be aligned.”

Cost Concerns
The HIMSS bar-coding task force agrees with the FDA’s estimate that implementing bar-coded medication administration may cost a little more than $2,000 per bed. “That assumes that you already have a wireless infrastructure and that a pharmacy system and order communication system are in place,” says Simpson.

“Our second implementation amounted to about $1.5 million, including an upgrade of the wireless network and purchasing scanners,” says Schumann. “We had an enterprise contract with the vendor. Our third and current implementation included the replacement of 300 scanners and adding 150 scanners to achieve broader implementation and added up to $950,000. Our previous implementations defrayed the costs of foundational elements of a wireless network expansion and process redesign.”

Douglas estimates that scanners cost approximately $200 per unit, while tethered imagers cost between $300 and $400, with wireless imagers running close to $800 per unit. “That cost difference makes management want to use imagers and tethered devices, but for patient satisfaction and for nursing and pharmacy efficiency, I recommend buying wireless imagers,” he says. “An armband printer costs us about $1,600. We have them at all the points of admission because we want to get patients processed quickly.”

Medication and Beyond
At Providence Health & Services, the neonatal ICU (NICU) is scheduled to become the latest area to go live with bar-coded medication administration. Providence currently does not use bar coding in the surgery center or the emergency department, where there is often insufficient time for an order to be written by a physician and processed by a pharmacist before the drug can be administered to a critical patient. However, bar-coded medication administration could be used to record what was administered to a patient in these settings even without the existence of an order, although there would be no ability to confirm the “five rights” (right medication, right dose, right time, right route, right patient) of medication administration without an order in the system.

Children’s Medical is exploring two additional applications for bar coding, one being mothers’ breast milk. “We have a growing NICU, where many mothers pump their breast milk,” says Schumann. “Bar coding will ensure that babies get the right milk.” Another initiative is to use bar coding in specimen collection. The bar code will be generated at the time of order, attached to the specimen container, and then matched up with the patient’s armband bar code before being sent to the lab for analysis.

— Alice Shepherd is a southern California-based business-to-business journalist specializing in healthcare topics.