Introduction:

1. Reduction of Medication Errors Following Implementation of CPOE and Medication Bar Code Scanning in the NICU Advocate Lutheran General Children’s Hospital Jeffrey George, DO; Cheryl Fornowski, RN; Jean Blazey, RN; Jeanne Wiesbrock, RN; Patricia Madden, PharmD; Raghbir Benawra, MD; Anca Negru; Tom Setter, RRT; Joyce Wright, RN; Kim Jenkins, RN; Ramesh Muthukumar, MD; and NICU nursing staff Introduction: Introduction: Results: • On December 14, 2009, the NICU achieved 81% CPOE usage • CPOE usage increased from 8% to 100% of eligible orders during a twelve month period • Medication errors influenced by CPOE decreased from 5.4 per month to 1.7 per month after implementation of CPOE • After introducing medication bar code scanning we saw a further decrease in med errors to 0.18 per month • Of those med errors which could be influenced by CPOE or med bar code scanning, we have not had a single medication error reported in the last 5 months. Computerized provider order entry (CPOE) has been shown to decrease medical errors and enhance patient safety. In February, 2009 our NICU began transition from paper orders to CPOE. As new electronic order sets were introduced we tracked the number of medication errors and unintended consequences. Medication bar code scanning was implemented in May, 2010 to facilitate further reduction of medication errors. • Initial Aims included: • Eighty percent of CPOE eligible • orders will be entered electronically • by December 31, 2009 • Track and manage unintended • consequences • Monitor medication errors as we transition to CPOE • Extended Aims: • Maintain CPOE usage at 100% of eligible orders • Monitor and mitigate unintended consequences • Monitor and mitigate medication errors that can be influenced by CPOE and Medication Bar Code Scanning Methods: The NICU multidisciplinary CPOE team met biweekly to design, build, and refine electronic order sets. Medication errors were self-reported and tracked utilizing the electronic MIDAS system. A baseline of monthly medication errors was determined using the prior year’s data. Unintended consequences were documented on a clipboard, tracked, and managed as they occurred. Admission Order Set introduced Discussion: • The NICU currently has 100% CPOE usage of eligible orders. • The number of unintended consequences increased as order sets were introduced. • Eighty percent of unintended consequences were workflow related. • Medication errors have decreased more than 98% since implementation of CPOE and medication bar code scanning. • Keys to our success include a multidisciplinary approach and a gradual rollout of new order sets. • The NICU was one of the first in our hospital system to trial CareMobile, an electronic medication bar coding system. • The combined use of CPOE and electronic bar coding had the greatest potential for preventing medication errors related to dosing, patient identification, and medication administration. References: Stavroudis, T., Miller, M., Lehman, C. (2008). Medication errors in neonates. Clinics in Perinatology, 35, 141-161.