“Implementing A Bar-Coded Bedside Medication Administration System” Presented by: Barbara Seebold RN Over the past few years, hospital organizations have increasingly looked to new technology solutions to improve patient safety. Barcode technology is an especially promising approach in the effort to reduce medical errors. While barcode technology has been used for quite some time in many hospital applications, it has only recently been used to address patient safety.

Objectives Describe the Barcode System Describe the benefits of barcode medication administration system Describe the hardware and software in the barcode system Evaluate the Usability of the Software (Mitch Work,2005)

Objectives Summarize The Criteria Review of Information System Recite a Recommendation Summarize the advantages and disadvantages of barcode medication administration system Summarize the legal and ethical issues of barcode medication administration system Describe the Nurse Informaticist Competencies, Functions and Responsibilities (St. Luke’s 2008, Cummings and Ratko, 2005, LaDuke 2009)

System Description Barcodes provide valuable verification of medication administration , assuring "five rights" are confirmed Barcode technology at bedside shows impressive gains in reducing medication administration errors (Mitch Work,2005, Sakowski, 2006) Medical errors result in 44,000–98,000 deaths per year—more deaths than those caused by highway accidents, breast cancer, or AIDS. BPOC systems are believed to be effective in preventing medication administration errors but are currently implemented in only about 2% of U.S. hospitals.

Utilized Hardware Laptops in patient rooms instead of computers on carts Wireless bar code readers Bar-code point-of-care Automated drug-dispensing systems and Robotics (St. Luke’s 2008) There's a bit of confusion when most people think of wireless barcode scanners. Sometimes, an application will beg a device that works just like its corded brother, but you need the mobility of being able to walk away from the PC to capture the data. Other times, you'll want to collect data far away from any PC but then have it moved from the device to the PC when you return. Because the scanner is portable, it can be called a wireless barcode reader, point of care. Automated dispensing systems are drug storage devices or cabinets that electronically dispense medications in a controlled fashion and track medication use. Robotics is the engineering science and technology of robots, and their design, manufacture, application, and structural disposition. Robotics is related to electronics, mechanics, and software.

Laptops (St. Luke’s, 2008) Acceptable to all parties Priority for hardware ease-of-use Acceptable to all parties Soliciting feedback and including pharmacy and clinical personnel Getting nursing input was essential in device selection (St. Luke’s, 2008) Governing decisions established priority for hardware ease-of-use, bedside point-of-care information access and only considered recommendations acceptable to all parties.By soliciting feedback and including pharmacy and clinical personnel in solution definition, all participants were supportive during implementation. "Getting nursing input was essential in device selection; however, it was the Information Services Manager who suggested placing a laptop in each patient room, which was ultimately the best solution for care at bedside.

Utilized Software Implementation of e-MAR in inpatient areas Computerized physician order entry (St. Luke’s, 2008)

eMar Caregiver establishes Bluetooth connection between bar code reader and laptop Caregiver logs in by scanning identification badge and entering PIN Caregiver identifies patient by scanning the patient identification wristband Caregiver scans dosed medication with either manufacture or hospital generated barcode Software ready at bedside with patient-specific information viewable to caregiver during medication administration (St. Luke’s, 2008)

eMar Caregiver watches on-screen for warnings of 'Five Rights' violations - Right Patient - Right Medication - Right Dose - Right Time - Right Method of Administration (St. Luke’s 2008) If any of the “Five Rights” are violated, an on-screen warning will flash alerting the care giver of the violation.

eMar Caregiver reviews warnings, and determines next step Caregiver exercises clinical decision-making responsibilities and documents decisions/actions All data captured/actions taken are stored in patient's medication administration record (St. Luke’s, 2008) With the eMAR solution, a caregiver enters a patient room and establishes the Bluetooth connection between the bar code reader and the laptop. Caregivers log in to the system by scanning their ID badges and entering in their PINs. Then, they scan the patient’s bar-coded wristband and the medication to be dispensed. The software on the PC displays the patient information specific to the medication and reviews the information according to the “five rights”: right patient, right medication, right dose, right time, right method. Based on the review of the “five rights,” the caregiver decides if the medication is appropriate and administers it if needed. The caregiver retains the decision-making responsibilities. All actions taken by caregivers are stored in real time in the patient’s medication administration record. The eMAR system helps reduce medication administration errors and overall costs of care, as well as increase patient safety and accurate reporting.

Usability of eMar (McGonigle, 2009) Adequate design characteristics Focus group used to begin process of use Understandable and easy to learn interface Problems with system detected early and worked out End users evaluation passed for final use (McGonigle, 2009) The software was designed to improve medication administration accuracy and to generate online patient medication records. A focus application is typically recommended. This is performed on a single unit and serves to test the technology at all levels. Only after a successful pilot is functional for a specific period of time should the technology be rolled out on a larger scale. In addition to testing durability, actively involving the nursing staff increased the buy-in and enthusiasm for the project. These pilot units provide the opportunity to correct glitches and assess impact to workflow, before proceeding to larger and more complex areas of the hospital. A total of approximately 100 nurses were trained for these units. Training was conducted 48 hours prior to go-live. Eight super users were utilized in the training and were present on the units during the implementation. Going forward, new staff will be trained exclusively by the super users, eliminating the need for ongoing training by the vendor and reducing costs.success of the barcode medication administration system at can be attributed to not only the use of state-of-the-art technology, but also to a carefully constructed, fully communicated work plan that included clearly identified new work processes and a thorough staff orientation and training program.

Review Of Information System Clinical information system Physicians, Nurses and many others use this application to monitor patient care Allows for the function of scanning and documentation Configuration used is the Workstation Health level 7 is the data standard Clinical Care classification scheme (McGonigle, 2009)

Recommendation YES, I recommend this system to others implementing this trend because I have used it so I have experienced it and already know how it works and have no trouble with it. It is very easy once you get to know it. It may not seem that way once you start, but after you learn it, it is very, very easy.

Advantages Reduction of medication administration errors Increased patient safety and accurate reporting Improved communication between departments Improved process integration and information sharing Reduction in overall cost of care Valuable management-level decision-making tools (St. Luke’s 2008)

Advantages Decrease errors: right medication, right route, right patient, right amount, right time Increased efficiency at bedside Minimally increasing nurse staffing time requirements Improve nursing staff job satisfaction Improve patient satisfaction Generate positive public relations with the local community (Mitch Work,2005) (

Disadvantages Barcode scanning can interrupt nurse workflow processes, leading to frustration/fatigue among staff. Barcode equipment must be reliable, readily available, and user-friendly to be used effectively. Select barcode technologies may lack certain desirable features/functions, which limit their usefulness. Barcode system approaches to complex IV solutions, non-typical formulations, and other pharmacy compounded products are still in the development phase. Interfacing between various hospital computer systems can be problematic. (Cummings and Ratko, 2005) Despite the general acceptance that BCMA systems are valuable for patient safety, their use still has challenges, potential disadvantages, and may even introduce different types of errors. Errors can occur in the printed barcode label (patient or drug). Not all drugs will contain manufacturer barcodes, and not all manufacturer codes are standardized and/or map to customized hospital pharmacy formulary databases. Procedures may contain loopholes that enable users to circumvent key steps, thus negating error safeguards.

Legal/Ethical Issues Scan bar-code on the patient's ID wristband Scanning is a form of documentation Scan bar-code on the patient's ID wristband Scan medication bar code after removing the medication Investigation could constitute professional misconduct Criminal charges Nurses can and have lost their jobs (LaDuke 2009) Scanning is a form of documentation, because it transfers information into the patient's medical record. If you're required to scan the bar code on the patient's ID wristband but you scan something else, you're practicing a form of deception: You didn't scan the patient's ID band, but you made it look like you did. When you scan a medication bar code after you've already removed the medication from its packaging, you're also deceiving the system. You didn't scan the medication before you opened it, but you made it look like you did. If something happens that leads to an investigation, your facility's legal staff could decide these actions constitute professional misconduct and require a report to your state's board of nursing. If a patient is harmed as a result of your actions, you could be further subjected to a civil suit. Criminal charges could be brought if your negligence resulted in a patient's permanent injury or death. Finally, nurses can and have lost their jobs for this kind of practice, which employers consider dishonest. Facilities have policies that specify disciplinary actions to be taken in response to procedure violations. If you're terminated, your ability to secure a new job elsewhere could be threatened if the facility tells prospective employers why you were terminated when called for a routine background check.

Nurse Informaticist Competencies, Functions and Responsibilities Establishes connection between bar code reader and laptop Logs in by scanning identification badge and entering PIN Identifies patient by scanning the patient identification wristband Scans dosed medication with either manufacture or hospital generated barcode Watches on-screen for warnings of 'Five Rights' violations Reviews warnings, determines next step, exercises decision-making responsibilities, documents decisions/actions (St. Luke’s 2008) Each scanning activity initiates wireless information transfer. The bar code reader captures a bar code image, decodes the information and sends data to the laptop computer through the use of Bluetooth wireless technology. All data captured/actions taken are stored in the patient's medication administration record in real-time.

Summary Having BPOC in place is the ultimate objective Addressing Pre-BPOC situations is a purposeful and well thought out method This can be a welcomed precursor that aids in determining the needs of the institution about BPOC Although having BPOC in place is the ultimate objective - anything that can be done Pre-BPOC, to prevent medication errors is highly desirable and will do a lot to eliminate errors before BPOC is in place. Addressing Pre-BPOC situations is a purposeful and well thought out method to get the pharmacy and hospital staff accustomed to the use of barcode scanning. This can be a welcomed precursor that aids in determining the needs of the institution about BPOC before the decisions on the large investments in hospital information systems and equipment have are made for BPOC

References McGonigle, D. and Mastrian, K. (2009), Nursing Informatics and the Foundation of Knowledge, Jones and Bartlett Publishers, Sudbury, Massachusetts, Retrieved March 1, 2010 Sakowski , J. (2006), Using a Bar-Coded Medication Administration System to Prevent Medication Errors, American Journal of Health-System Pharmacy, Retrieved January 31, 2010 from http://www.medscape.com/viewarticle/519719 St. Luke’s Hospital,(2008) Implementing a Bar Coded Medication Administration System. Retrieved January 31, 2010 from http://codecorp.com/stlukes.html

References Cummings, J. and Rayko, T. (2005) Bar-coding to Enhance Patient Safety, Patient Safety and Quality HealthCare, Retrieved February 1, 2010 from http://www.psqh.com/sepoct05/barcodingrfid1.html LaDuke, S. (2009) Playing it safe with bar code medication administration. Nursing 2010. Retrieved February 6, 2010 from http://journals.lww.com/nursing/Fulltext/2009/0500/Playing_ it_safe_with_bar_code_medication.17.aspx Work, M/ (2005)Improving Medication Safety with a Wireless, Mobile Barcode System in a Community Hospital, Patient Safety and Quality HealthCare, Retrieved February 1, 2010 from http://www.psqh.com/mayjun05/casestudy.html