Raising the Bar: Using Data from Bar Code Medication Administration to Improve Care Dr. Michele Evink MS, PharmD, CGP Mona Parekh MLS (ASCP) CM, MHA

Learning Objectives Participants will be able to describe the differences in data available with bar code administration. Participants will be able to describe a process used to turn data into opportunities for improvement. Participants will be able to discuss the resources needed to maintain and monitor bar code administration.

Pre Test: True or False Moving to bar code administration will make medication administration faster Bar code administration is a lot of work to set up, but maintenance is minimal Using bar code administration means losing the opportunity for a lot of data Involving many departments in process improvement is important to increasing safety

Making the Case Adoption in other industries ▫Package delivery ▫Retail stores ▫Rental cars ▫Trains: the start of it all Data analysis and predictive technology ▫The WalMart model Using data to make evidence based changes Hays, 2010

Making the Case Publication of To Err is Human Adoption of technology in healthcare ▫Computer systems ▫Distribution systems ▫Computerized charting Patient safety initiatives Institute of Medicine, 2000 Johnson, 2002

Making the Case On average one medication error per patient per day Approximately 400,000 errors each year Conservative estimate of cost to treat errors per year $3.5 Billion HealthGrades, 2009

It Dawns on Healthcare The Veterans Health Administration was inspired to develop its own bar-coding system when a nurse was returning a rental car. Seeing the rental car company employee use a hand-held device to scan a bar code located in the trunk of the returned car led the nurse to consider a similar application for identifying patients and medications. Dubin, 2010

2009 ASHP Informatics Assessment Please see the separate sheet with the data table BCMA increased from 1.5%-27.9% in all hospitals from Hospitals <50 staffed beds 9%-19% Pedersen, 2008

The Data Challenge Bar code technology is unique and specific Not all items come bar coded Compensating for deficiencies ▫½ tabs, multiple tabs It doesn’t work unless you use it Someone has to review it

The Data Challenge Must examine information to find potential errors Must engage all departments to analyze data Must be creative in data analysis to uncover process and procedural changes

The Data Challenge Refer to Medication Verification Compliance Report, Warning Report Represents a 10 day period Can show patterns (medications, nurses, computers) Shows nothing without scrutiny

The Data Challenge

Refer to Medication Verification Compliance Report, Override Report New data available ▫Date and time of administration  Change in occurrence report trigger  Use data to improve processes  The philosophy of “late” medications

The Data Challenge A whole new world of near misses GREAT CATCHES! ▫Reveal processes that work ▫Encouraging reporting ▫The great catch as a gift

The Data Challenge The Just Culture ▫To err is human ▫To drift is natural ▫To purposefully vary from established safe practices is negligence.

The Data Challenge Analysis of the real issue ▫Reworking and reworking and reworking and reworking of the occurrence report to reveal if error related to  Order Entry  Distribution  Administration  System

The Data Challenge Analysis of the real issue ▫Further break down by nursing to look at  White board use  Staffing  Other issues related to the occurrence

Raising the Bar Recognize the barriers ▫Bar code administration is safer, not faster ▫Any point in the process derails the whole thing  Patient’s armband  Order entry  Medication  Computer  Scanner  Wireless points

Raising the Bar Full Court Press ▫Pharmacy ▫Nursing ▫IT ▫Quality Improvement ▫Others?

Raising the Bar Creating awareness ▫Posting by employee number ▫Posting by shift ▫On screen “tachometer” Common theme: Awareness of performance as close to real time as possible

Raising the Bar Daily medication rounding Analyze occurrences and compliance report Coordinate efforts ▫Nursing ▫QI ▫Clinical informatics ▫Pharmacy  Pharmacist  Pharmacy technician

Raising the Bar Refer to override and warning reports

Raising the Bar Issues uncovered ▫Times out of sync between hospital system and information system ▫Wireless connections not strong enough ▫Disappearing data ▫The work arounds

Raising the Bar Processes improved ▫Nurse awareness of medications due  Electronic MAR  Whiteboard ▫Pharmacy packaging  Changed to 10 digit code  Increased size of bar code  Changed to a color printer  Upgraded packaging software

Raising the Bar Processes improved ▫Pharmacy processes  Generating automatic reset of all NDC’s in system  Scanning and updating of items  Verify NDC number of current vs. product received  Updating bar codes  Constant process  Understanding of the reporting

Medication Rounding Daily analysis of the report Feedback to nurses through no occurrence stars Goals after so many star days ▫Food, drawing, tickets

Importance of a Good Start Safety discussion with nursing students Orientation of all new staff nurses includes 90 minutes in the pharmacy Nurse learns about the set up of the pharmacy Participates in a check of a patient drawer

Importance of a Good Start Safety over and over Introduce tallman lettering, warning stickers Views various safety mechanisms ▫Stickers ▫Check Dosage ▫Colors ▫Bags

Efforts Through Quality Improvement Daily medication rounding of occurrences Monthly medication committee meetings Medication Focus Group ▫In depth analysis of each occurrence to recommend process changes Medication white board at nursing stations Year end goals established at beginning of fiscal year

Efforts Through Quality Improvement Data drill down ▫Nurse ▫Type of error ▫Root cause of error ▫Departments involved Data posting ▫Department ▫Hospital ▫Senior leadership and hospital board

Medication Error Reporting at the Board Level

Final Thoughts Bar code administration is a process, not a project Constant attention to data will improve patient safety Constant feedback of data to nurses will improve patient safety Celebrate wins

Post Test Name one type of data that is available with bar code administration that wasn’t available with manual administration True or False: Using bar codes makes medication administration faster True or False: Looking at late medication administration is meaningless, it only tells you people weren’t organized

Post Test True or False: Data on bar code administration is sensitive and should be kept at the administrative level Name one barrier to implementing and maintaining bar code administration

Contact Information Dr. Michele Evink MS, PharmD Mona Parekh MLS (ASCP) CM, MHA

References Institute of Medicine. (2000). To err is human: Building a safer health system. L. T. Kohn, J. Corrigan, & M. S. Donaldson (Eds.). Washington, DC: National Academies Press Johnson, C. L., Carlson, R. A, Tucker, C. L., & Willette, C. (2002). Using BCMA software to improve patient safety in veterans administration medical centers. Journal of Healthcare Information Management, 16 (1)

References The Sixth Annual HealthGrades Patient Safety in American Hospitals Study, April Available at: americanhospitalsstudy2009.pdf. Accessed May 12, 2010 The Seventh Annual HealthGrades Patient Safety in American Hospitals Study, March Available at: americanhospitalsstudy2010.pdf. Accessed May 12, 2010

References Pedersen CA, Gumpper KF. ASHP National Survey on Informatics: Assessment of the Adoption and Use of Pharmacy Informatics in US Hospitals Am J Health Syst Pharm Dec 1;65(23): Hays CL. 2004, November 14. What Wal-Mart Knows About Customers' Habits. NY Times. Retrieved from ney/14wal.html. Accessed May 12, 2010