Bringing Barcoding to the Bedside

1. Bringing Barcoding to the Bedside Challenges & Benefits of Implementing a Barcode Point of Care Medication Administration System James Douglas, RN and Susanne Larrabee, RPh Northern Michigan Regional Health System - Petoskey, MI

2. Session Overview • Identify implementation challenges and strategies employed • Describe the role of Bar Code Point of Care (BPOC) technology in capturing medication error data • Identify factors influencing data interpretation and analysis • Discuss benefits of implementing BPOC

3. Northern Michigan Regional Health System • 243 bed Regional Referral Center located in Petoskey, Michigan • Major Services Lines: Cardiology Oncology Neurosciences Orthopedics

4. 1Institute of Medicine 1999 (IOM) 2Agency for Health Care Research and Quality (AHRQ) 3IOM 2001 Medication Error Facts • 7,000 Americans die annually1 • $5.6 million per hospital2 • Hospitals urged to use information technology to collect data to reduce and prevent medication errors, adverse drug events, (never-events, sentinel events, near-misses, near-hits, hazardous conditions)3

5. Scope of the Problem • For every 100 hospital admissions, 6.5 experience an ADE (adverse drug event). • For every 100 medication errors that occur, approximately 1% harm the patient. • 5 serious medication errors occur for every 10,000 medications administered. • Errors in ordering are much more likely to be intercepted (48%) than those in the administration stage (0%) 1Bates D.W. et al. Incidence of Adverse Drug Events and Potential Adverse Drug Events, JAMA 1995;274:29-34

6. Hospital Buy In • Change Philosophy • Champions - all levels of staff • Readiness of staff • Nursing, Pharmacy and Information Services manager accountability for successful implementation • Mandatory nursing, respiratory and pharmacy training

7. BPOC Bedside Device • Wireless Laptop computerwith a touch screen and bar code scanner • Deployed on 148 beds ICU, CVU and Med-Surg Units on 10/31/2001. • Average daily census of 100 patients on these units • Average monthly medication administrationsof 50,000 doses.

8. Training • Nursing/RT: Theory, basic use, and troubleshooting • Pharmacy: Theory, order entry, and troubleshooting • Training Methods: Class, Computer Based, One-on-One • Don’t forget the Physicians!

9. Nurse barcode scans name tag Nurse barcode scans patient identification bracelet Patient MAR appears on bedside laptop Scheduled and prn meds are scanned Warnings/alerts are issued when indicated Barcode Technology

10. Care Giver Scanning • Permanent identifier • Ergonomics • Who, where and when

11. Patient Scanning • Durability • Reliability • Is the wrist band on the wrist? • Addressing patient concerns

12. Medication Scanning • Manufacturer bar codes • Repackaging • Adding barcodes to existing package • Quality control

13. User Issues • How to communicate and collect issues on a daily basis (Nursing/Pharmacy/IT) • A plan for disseminating issues to proper person(s) • Tracking, discussing and prioritizing issues • Who can fix issues on a daily basis?

14. Capturing Medication Error Data

15. 1. Scanning compliance! 2. Percentage of medications with bar codes! 3. Users paying attention to the warning messages! How do you prevent medication errors with bar code technology?

16. Give the Med to the Computer before you give it to the Patient!!!!!!!!!!!!!!!!! Scanning takes longer, but it is the best way to prevent a med error! Pay attention to the warning messages!!

17. Cancel Cancel Error Prevented Error Prevented Warning Message Algorithm Nurse Response Warning Message Continue Administer Potential Error

18. Warning Message Definitions Dose Omitted: A prior dose has not been given. Maximum Daily Dose Exceeded: The 24-hour maximum safe dose will be exceeded. Route Not Ordered: The order does not specify the route of administration. Dose Too Soon: A medication is about to be given Not on Profile: The selected medication has not been ordered for the patient. Wrong Dose Range: The medication entered does NOT match the prescribed dose. Dose Late: A medication is being given greater than one hour after it was due. Orders Discontinued: The selected medication has been stopped by the physician. Wrong Single Dose Value: The medication that was bar-coded is NOT the actual prescribed dose. Duplicate Medication: This medication has already been selected to be given. Order Expired: The order for this medication is no longer valid. Future Order: The selected medication is not currently scheduled.

19. Since “going live” with BPOC Oct 31st 2001 Total Medications Administered= 931,780 Total Errors Messages= 285,849 Total Confirmed Errors Prevented= 2,493 (0.87%)

22. Aspirin Colace Lortab* Ketorolac* Metoprolol* Pepcid Percocet* Prevacid Tylenol Zofran *potential for harm if given incorrectly Top 10 Medications Involved with Errors Prevented

23. Hospital Risk Management Have they reported and measured your hospital’s medication errors ? (Most likely they have been doing it for years and years.) Can you use them to show med error reduction after implementing bar code technology?

24. Up 29% Up 50% Down 31%

25. Impact on med errors reported since “going live” Oct 31st 2001 live

28. So now that you have all this data what are you going to do with it? Root Cause Analysis Errors Reported+Errors Prevented You now know “Total Number of Medications Administered” by day, week, month, user, unit, etc.

29. Benefits and Value of a B.P.O.C. System

30. No error/harm– but potentially injurious circumstances A> Error occurred, didn’t reach patient B> C> Error reached patient, not harmful J. Smetzer ISMP Not harmful, increased monitoring D> NCC-MERP - National Coordinating Council Medication Error Reporting Prevention

31. Additional treatment, intervention, temporary harm E> Prolonged hospitalization, temporary harm F> G> Permanent patient harm Near-death event (Code Blue, ICU required) H> I> Death

32. Cost of Adverse Drug Events (ADEs) • JCAHO 1998 • 1 ADE costs $2,000 (excluding malpractice) • Jury Verdict Research • Average malpractice award for a medication error is $636,000 • CA HealthCare Foundation • Preventable ADE costs $5,000 • 6.5% of all hospital admissions result in ADE • Leapfrog 2001 • 1 med error costs $10 • 1 ADE costs $2,000 • Schneider 1995 • Med error requiring extra lab or treatment costs $95 to $227 • Med error prolonging length of stay costs $2,596 • Med error resulting in near-death experience costs $2,640

33. No error/harm– but potentially injurious circumstances A> Error occurred, didn’t reach patient B> $101 C> Error reached patient, not harmful Not harmful, increased monitoring D> 1Birkmeyer et al. 2001

34. Additional treatment, intervention, temporary harm E> Prolonged hospitalization, temporary harm F> Permanent patient harm (Code Blue, ICU required G> Near-death event (Code Blue, ICU required) H> $2,300 I> Death

35. Potential Severity of Medication Errors Prevented • Enteric coated Aspirin given instead of chewable=C • Zofran q6hrs given 1 hour early=C • Lovenox 130mg q12hrs given 6 hours early=D • Apresoline 100mg given 30 minutes after previous dose was given=E

36. 2003 378 med errors prevented 311- were C’s 65- were D’s 2- were E’s (17.5%) of errors prevented were potentially serious)

37. Benefits of BPOC • Classify & Quantify Med Errors Prevented • Helps Meet Regulatory Standards • Patient Safety Mission • Root-Cause Analysis to drive Process Improvement

38. Questions?