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Bar Code Medication Administration(BCMA) Definitions, Impact on Medication Errors, Fundamental Essentials, and Using Data to Improve Performance Bill Templeman, Pharm.D. Inpatient Pharmacy Quality Supervisor Kaiser Permanente Riverside Medical Center 2

Disclosure The speaker had no conflicts of interest to disclose 3

Learning Objectives  Understand the definitions of BCMA  Describe the effect of BCMA compliance can have on medication errors  Identify the essential components of a successful BCMA program  Explain how using reporting data can improve system and user performance 4

Definitions of Barcode Medication Administration  BCMA is an additional layer of safety to ensure the correct patient is identified and medication is administered  The nurse, at the time of administration, will scan:  The patient’s armband to assure the correct patient  Scan the medication bar code to assure the correct medication is being administered 5

BCMA Override  A BCMA override is when a nurse electronically documents a medication administration, even after the system displays an alert that indicates there is a problem with patient identification, drug strength, dosage form or administration time. 6

BCMA Overrides  BCMA overrides are acceptable under certain circumstances:  Medication administered in the operating room  Medications administered during a code or urgent procedural sedation situation  Computer downtime 7

BCMA Medication Override Warnings This Medication was not scanned prior to administration 8

BCMA Medication Override Alerts 9 #Alert NameAlert DescriptionAlert Example 1 Barcode Not Recognized Alert Bar code scanned is not recognized in KP Health Connect Product bar code not recognized 2 Wrong Medication Alert Bar code scan is recognized in KP Health Connect but the medication is not on the patient’s MAR No administrable medications were found in this patient’s record 3Other Alerts Medication scanned is no longer active on the patient’s MAR No active orders were found in this patient’s record

BCMA Override Reason Documentation “ACTION” “PT. NOT SCANNED” “MED NOT SCANNED” 10

Medications Errors Originate and are Intercepted Prescribing Origination 39% Interception 48% Transcribing Origination 12% Interception 33% Dispensing Origination 11% Interception 34% Administration Origination 38% Interception 2% Leape LL, Bates DW, Cullen DJ, et al. Systems Analysis of Adverse Drug Events. JAMA. 1995;274(1):

ISMP Estimation of Inpatient Medication Errors In 2001, Institute for Safe Medication Practices (ISMP) estimated, in the United States’ hospitals, daily there were approximately 320,000 medication errors:  100,000 during medication administration  35,000 during drug dispensing ISMP Acute Care Edition, July 25,

Medication Errors  Each year, an estimated 7,000 deaths are linked to medication errors [1].  BCMA assists personnel that administer medication in compliance with the "Five Rights" of medication administration: right patient, right dose, right route, right time, and right medication [2]. 1. Institute of Medicine. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health Care System. Committee on Quality of Health Care in America. Washington, DC: National Academy Press; Perry A, Shah M, Englebright J. Improving Safety with Barcode-Enabled Medication Administration. Patient Safety and Healthcare Quality. May/ June

Effectiveness of Error Reduction From “Words on Design and Life “ by Cassie McDaniel 14

The Swiss Cheese model by James Reason 15

An Example of Swiss Cheese  Magnesium 2gm on shortage  Patients identified, monitored no harm  Root cause conducted Pharmacy- Wrong product ordered and placed in floor stock Look-alike medication Nurses not scanning medication in real time 16

BCMA Effect on Medication Errors  A study of 14,041 medication administrations showed 1 :  Error rate of 11.5% on an unit not using BCMA and 6.8% on a unit using BCMA; a 41.4% relative reduction in errors  Rate of potential adverse drug events fell from 3.1% without the use of the bar-code eMAR to 1.6% with its use, representing a 50.8% relative reduction 1 Poon, et al. “Effect of bar-code technology on the safety of medication administration.” N Engl J Med May 6;362(18):

Kaiser Permanente Riverside Data: BCMA Compliance Related to Medication Errors 18

Use of Bar Code Technology to Decrease Dispensing Errors  Scan on automated dispensing cabinet (ADC) medication fill  All medications need to be checked by a pharmacist prior to distribution from the pharmacy  The technician is to scan all medications prior to filling the ADC 19

Use of Bar Code Technology to Decrease Dispensing Errors  “Dispense Prep” and “Dispense Check”  The technician and pharmacist scan the computer generated order bar code and then scan the medication  If the scanned medication matches the scanned medication, the screen will turn green  If the scanned medication does not match, a warning of the mismatch will display 20

Dispense Check Screen Shot 21 The product from the Health Connect label matches the product scanned

Use of Bar Code Technology to Track Items Used in Intravenous Compounding  Additives for IV compounded products are scanned  Lot number, manufacturer and expiration date is entered into an electronic IV compounding log  Pharmacist checks and initials compounded item label  Scans label bar code and also verifies base solution and additives electronically 22

Essential Foundations of a Successful BCMA Program  Teamwork:  IT  Pharmacy  Nursing and Nursing Managers  Data and usable reports  Impact on decreasing medication errors 23

Essential Foundations of a Successful BCMA Program Software  Reliable EMR software and computer network  The computer medication system is compatible with the scanners being used  The scanners can transmit the data to the medical record  The scanners are correctly linked to the computer system (either mobile or stationary ) 24

Essential Foundations of a Successful BCMA Program Hardware  Functional and reliable barcode scanners  Plenty of workstations  Scanners are working properly 25

Information Technology’s Essential Role After Implementation  Ensure scanners are working properly  Ensure identified issues are addressed in a timely manner  Ensure system is reliable with minimal downtime 26

Pharmacy’s Role in a Successful BCMA Program  Develop a method for adding the correct bar codes for multi-dose products  Inhaler, creams, ointments, insulins, multi-dose containers  Develop a bar coding label hierarchy  Pharmacy placed bar code label- > manufacturer’s bar code-> computer generated order ID bar code 27

Pharmacy’s Essential Role in a Successful BCMA Program  All drugs dispensed from the pharmacy have readable barcodes  All dispensed drugs are built in EMR database  One medication record for multiple manufacturers’ product  The correct ordered product is dispensed from the pharmacy 28

Pharmacy’s Role in a Successful BCMA Program  The pharmacy computer generated bar code label should only be used as a last resort  Pharmacy compounded products  Medications not in the pharmacy database  The pharmacy generated bar code label usually displays the order number, which does not ensure the correct product was dispensed. 29

Nursing Management’s Role in a Successful BCMA Program  Education of staff  Holding staff accountable for workarounds and non-compliance with correct BCMA work flow  Using data to identify and counsel non- compliant users  Strong relationships with: pharmacy, informatics, nursing staff and the IT department 30

Nursing’s Role in a Successful BCMA Program  Buy in with capitalizing on initial successes and increased patient safety  Performing BCMA compliant with established workflow :  Not using BCMA labels not attached to a medication  Not scanning in real time  Reporting medications that do not scan or scanners that do not work 31

BCMA Report Content Contents:  Overall Medical Center compliance  Unit specific compliance  User specific compliance  Hour and date  Scanning compliance by medication 32

BCMA Report Content  BCMA compliance by Medical Center and unit type  High Alert medication overrides  Top twenty medications overrides and rationale for overrides  Raw data on armband and medication overrides  Wrong medication alerts 33

BCMA Report Content  Wrong medication alerts  Respiratory BCMA compliance  Many other data sets and graphs 34

Overall User Summary Table 35

Users with No Overrides 36

High Outlier Summary 37

High Outlier Report 38

Conclusion  The number of medication errors can be decreased by a robust BCMA process.  It takes teamwork with pharmacy, nursing and IT for a successful BCMA program  Bar coding is just not for administration anymore, pharmacy can use this technology to dramatically reduce the number of dispensing and ADC refilling errors  Reporting can be used to increase compliance and identify system issues 39

Acknowledgements  Don Kaplan, Pharm.D., Inpatient Pharmacy Practice Coordinator, Kaiser Southern California Region  Michelle Larsen, Kaiser Southern California Region Inpatient Pharmacy Project Manager  Kal Khoury, Pharm.D, Area Pharmacy Director Kaiser Riverside  Dale Timothy, RPh, MBA, Inpatient Pharmacy Director, Kaiser Riverside  Christel Cheng, BSBA, Administrative Assistant Kaiser Riverside 40

Thank you for attending! Please write down your CE secret code. All ACPE credit must be claimed online no later than November 20, See Seminar Program Book for details. 41