EMAR Bar Coding Practice Recommendations and Project Learnings

1. San Antonio, Texas eMAR & Bar CodingPractice Recommendations and Project Learnings

2. 2 Project Risks Invalidating bedside verification with workarounds Packaging and labeling errors in pharmacy Changing federal regulations Emerging barcode symbologies Highest Project Risks Optimized Use of technology and potential error shifts Highest Project Risks Optimized Use of technology and potential error shifts

3. 3 The Solution ???

4. 4 Potential Project Impacts Reviewing/ re-engineering the delivery and administration of medications Redistributing work loads Changing work flow Creating virtual medication teams

5. 5 Who is impacted . . . Pharmacy Nursing/ Respiratory Therapy IT&S Others HIM Physicians Ancillary Departments

6. 6 Pharmacy Impact Accuracy and timeliness of order entry and turn around Bar Coding ALL medications Medication acquisition philosophy Items to contribution to pharmacy impact: Location, Hours/ Days of operation, Automation, State Regulations, Medication Distribution/ Order Entry, Turn around Time, Perceived Turnaround, Nursing model of care (primary, team, functional nursing) Items to contribution to pharmacy impact: Location, Hours/ Days of operation, Automation, State Regulations, Medication Distribution/ Order Entry, Turn around Time, Perceived Turnaround, Nursing model of care (primary, team, functional nursing)

7. 7 Quality Control Practice Recommendations Bar Coding Acquisition System Integrity with NDC Distribution Must include staging area

8. Multi Dose / Multi-Use Medication Practice Recommendations Insulin Inhalers Large Volume IV�s

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11. 11 Nursing Impact Model of care delivery Who do you want to give medications? Medication distribution system How do medications get from the pharmacy to the bedside? Consider RN vs. LVN/LPN, agency staff, faculty and students Consider medication carts vs. modified lap top carts vs. bedside devicesConsider RN vs. LVN/LPN, agency staff, faculty and students Consider medication carts vs. modified lap top carts vs. bedside devices

12. 12 Quality Control Practice Recommendations Order Acknowledgement Electronic Medication Administration Record sign off Impact to �Chart Check� Timely error prevention

13. 13 Pediatric/NICU Practice Recommendations Identify armband solution Pre-registration Processes Unit dose medications Address equipment issues Explore other uses for bar code technology

14. 14 Breast Milk Practice Recommendations Ensure appropriate mike gets to correct baby Assign barcode to milk and utilize barcode on armband Ensure QC process occurs

15. 15 Respiratory Therapy Impact Medication Administration Workflow Medication distribution system How do medications get from the pharmacy to the bedside?

16. 16 Respiratory Therapy Practice Recomendations Must have complete order or approved protocol Determine who will acknowledge/sign off orders Flow diagram process for RT orders from order written to treatment delivered

17. 17 Respiratory Therapy Practice Recommendations Determine process for inhalers Flow diagram process for bar coding and distribution of RT meds Use medications that have manufacturer barcodes where possible Enter as �scheduled� by physician

18. 18 IT&S Impact New Member of the Clinical Team WLAN Installation and Support Computer Management Equipment Maintenance, including pharmacy equipment

19. 19 General Practice Recommendations

20. 20 Infection Control Practice Recommendations Carts should be cleaned at least daily with hospital approved disinfectant Carts may be used in isolation rooms Carts should be cleaned before leaving the room if contaminated and when used in isolation Patient Safety equipment can be safely used in all patient care areas � exception: Known SARS or Small Pox

21. 21 Armband Practice Recommendations Ensure that CODE 128 bar code is being used for armbands Ensure that ALL armbands use bar code that is compatible with eMAR at all points of entry (ER, Admitting, etc.) Train staff on correct application of armband and scanning techniques (Guides provided on eMAR website)

22. 22 Manager Practice Recommendations Reinforce the purpose of eMAR � not the action of scanning Direct Observation Establish policies/procedures to address high risk behavior Implement PI plan to improve scanning percentages � beware of work-arounds Make it easier to use the system than engage in work-arounds

23. 23 Culture Practice Recommendations Leadership Role Executive Walk rounds Observe nurses passing medications and observe patient verification by scanning Create an environment for nurses to feel comfortable reporting when patient verification is not being performed Use staff meetings and other opportunities to discuss barriers to verifying the patient and work on ways to overcome them

24. 24 Culture Practice Recommendations Reinforce with nursing the purpose of eMAR and the need to verify the patient with each medication administration Regardless of how long they have known the patient, how many patients they have or how confident they are�the system is flawed, mistakes will occur

25. 25 When you analyze current processes within any department of the hospital, you find lots of opportunities to streamline, simplify, and improve.When you analyze current processes within any department of the hospital, you find lots of opportunities to streamline, simplify, and improve.

26. 26 Patient Safety Theory- Blunt and Sharp End The next concept is that of blunt and sharp end. The blunt end usually encompasses policies, procedures, and resource allocation systems that impact how supplies, procedures and work are organized. The blunt end influences the systems in which practitioners work. Direct caregivers are considered the sharp end in the system because they are the direct interface with the patient. Combined with the Swiss Cheese model it is easy to see that when an error occurs, it is �visible� where the final error occurred, but all of the other systems, departments and other factors are not easily recognized. This point will be important to remember during the error analysis since multiple reasons or causes usually contribute to an error. The blunt end in a system may either be a barrier or an enabler for caregivers depending on how policies and procedures are designed. For example, if a medication error occurs it may be easy to blame the single nurse. What is not readily apparent are factors that may have contributed to the error such as the medication delivery being late; or delivered to the wrong unit; or a policy that required purchase of medications that were cheaper but look alike. These other �blunt ends� contribute to potential errors but are only noticed when made at the �sharp end�. The next concept is that of blunt and sharp end. The blunt end usually encompasses policies, procedures, and resource allocation systems that impact how supplies, procedures and work are organized. The blunt end influences the systems in which practitioners work. Direct caregivers are considered the sharp end in the system because they are the direct interface with the patient. Combined with the Swiss Cheese model it is easy to see that when an error occurs, it is �visible� where the final error occurred, but all of the other systems, departments and other factors are not easily recognized. This point will be important to remember during the error analysis since multiple reasons or causes usually contribute to an error. The blunt end in a system may either be a barrier or an enabler for caregivers depending on how policies and procedures are designed. For example, if a medication error occurs it may be easy to blame the single nurse. What is not readily apparent are factors that may have contributed to the error such as the medication delivery being late; or delivered to the wrong unit; or a policy that required purchase of medications that were cheaper but look alike. These other �blunt ends� contribute to potential errors but are only noticed when made at the �sharp end�.

27. 27 eMAR Process Maintenance??? Software Equipment Culture/process change

28. 28 Evolving� Software Future Development Allergy Integration Armbands Downtime Integrated issues list Usage in areas without pharmacist review Software Equipment

29. 29 Additional Considerations Clinical interface integration Smart Pumps Integration Dynamap Glucometer findings Workflow study on human factors integration