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Review of BCMA Literature as it Applies to Small Rural Hospitals

Barcode Medication Administration Awareness R esource P atient M anagement S ystem. Review of BCMA Literature as it Applies to Small Rural Hospitals. Presenters: David Taylor OIT BCMA Federal Lead Mollie Ayala OIT BCMA Co-Project Manager Michael Allen OIT Pharmacy Consultant

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Review of BCMA Literature as it Applies to Small Rural Hospitals

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  1. Barcode Medication Administration Awareness Resource Patient Management System Review of BCMA Literature as it Applies to Small Rural Hospitals

  2. Presenters: David Taylor OIT BCMA Federal Lead Mollie Ayala OIT BCMA Co-Project Manager Michael Allen OIT Pharmacy Consultant Phil Taylor OIT BCMA Nurse Lead Carla Stearle OIT Pharmacy Consultant Barcode Medication Administration

  3. Objectives • Summarize BCMA Literature as it applies to Small Rural Hospitals Special Thanks to: Diane Cooper, MSLS, AHIP Informationist / Biomedical Librarian NIH Library / Office of Research Services / National Institutes of Health Barcode Medication Administration

  4. Current Activities and Concerns(1 of 2) • The OIT BCMA Team is conducting a literature search learning more about the effect BCMA has had on facilities around the world • While BCMA has been shown to reduce medication administration errors in larger facilities, we have reason to wonder if it is so in smaller facilities, especially those with patient loads of 1-2 patients per month Barcode Medication Administration

  5. Current Activities and Concerns (2 of 2) • One unique factor is the size of the average IHS hospital and its relation to “small hospitals” cited in literature. The average “small hospital in the world is between 80 and 120 beds. Most IHS hospitals are not anywhere near that • We are developing the concept that in facilities with low census, due to reduced nurse exposure to the BCMA program in the computer, BCMA may present a new source of medication errors due to inexperience and the tendency to forget how to do something when it’s not being done all the time Barcode Medication Administration

  6. Factors that Contribute to Successful BCMA Implementation • Properly trained staff • Adequate Pharmacy Coverage • Adequate Number of Nursing Staff • Plentiful Resources • IT Support • Administrative Support Barcode Medication Administration

  7. Characteristics of Indian Health Care Hospitals • Total Number of IHS Hospitals: 37 • Total number of beds: 1185 beds (average 31.18 beds) • Average occupancy rate of 2.42% • Low ADPL (Average Daily Patient Load) • Limited Pharmacy and Information Technology (IT) coverage • High staff turnover • Limited resources Barcode Medication Administration

  8. Article Review • Most articles we reviewed on BCMA discussed pros and cons on BCMA implementation • Even the most positive articles still included a few caveats • Even the most negative still mentioned potential benefits under the right conditions • None failed to mention challenges in money, time, workload, or cooperation faced by a facility attempting to implement BCMA Barcode Medication Administration

  9. BCMA BenefitsSelected Articles • Patterson E, et al. “Improving Patient Safety by Identifying Side Effects from Introducing Bar Coding in Medication Administration”, J Am Med Inform Assoc. 2002;9:540–553. DOI 10.1197/jamia.M1061. Accessed online at http://jamia.bmj.com/ 2/4/2012 • Lawton G, Shields A. “Bar-Code verification of medication administration in a small hospital”. Am J Health-Syst Pharm. 2005; 62:2413-5 • Foote S, Coleman J. “Medication Administration: The Implementation Process of Bar-Coding for Medication Administration to Enhance Medication Safety.” Nursing Economics. 2008;3:207-210 • Poon E, et al. “Effect of Bar-Code Technology on the Safety of Medication Administration”, New England Journal of Medicine 2010;362:1698-707 • Maviglia S, et al. “Cost-Benefit Analysis of a Hospital Pharmacy Bar Code Solution”. ARCH INTERN MED/VOL 167, APR 23, 2007,788-794. Downloaded from www.archinternmed.com on March 16, 2012 Barcode Medication Administration

  10. Lawton Article (2005) • “Bar-Code verification of medication administration in a small hospital.” • Purpose: To assess the impact of Bar-Code Verification (BCV) on medication errors in a small private hospital • Methods: Observational study performed by documenting any potential errors that were prospectively identified by the BCV system • A 58-bed general acute care hospital implemented a wireless system of BCV on a new 36-bed combined intensive care and medical-surgical nursing unit. Lawton G, Shields A. “Bar-Code verification of medication administration in a small hospital”. Am J Health-Syst Pharm. 2005; 62:2413-5 Barcode Medication Administration

  11. Results • 1438 patient admissions (average daily census of 27, average length of stay 2.8 days • Over the nine-month study period, the BCV system detected and prevented 27 potential medication administration errors • The Potential Medication Errors Identified: • 13 (48%): wrong dose • (15%): administrations for which an order did not exist • 4 (15%): wrong patient • 3 (11%): wrong dosage form • 2 (7%): wrong time • 2 (7%): wrong drug • 11% Relative Risk Reduction in the rate of medication events • Estimated cost savings due to the avoidance of hospitalization by the reduction in potential errors: $72, 468 to $168,660. Lawton G, Shields A. “Bar-Code verification of medication administration in a small hospital”. Am J Health-Syst Pharm. 2005; 62:2413-5 Barcode Medication Administration

  12. Conclusions • BCV can reduce the overall frequency of medication administration errors • Nursing staff must maintain a high utilization of BCV to achieve the long-term benefits of reducing errors. • The pharmacy staff must be readily available to troubleshoot potential BCV problems • Accurate and timely order entry • Consistent Labeling • Prompt delivery • 24 Hour On-site Pharmacy Coverage Lawton G, Shields A. “Bar-Code verification of medication administration in a small hospital”. Am J Health-Syst Pharm. 2005; 62:2413-5 Barcode Medication Administration

  13. Maviglia Article (2007) • Brigham and Women’s Hospital (BWH) is a 735-bed, tertiary, academic, nonprofit medical center. Its inpatient pharmacy service dispenses approximately 6 million medication doses for 35 000 admissions annually. The hospital employs 61 fulltime pharmacists, 45 full-time pharmacy technicians, and 2500 registered nurses, who are responsible for most medication administration. • The study design was based on a pre-post comparison of error rates • Before bar coding, 0.19% of dispensed doses had errors with the potential to harm patients (potential ADEs, usually incorrect medication, strength, or dosage form). After implementing bar coding, the rate of potential ADEs from dispensing errors decreased to 0.07%. With approximately 6 million doses dispensed annually, this represents approximately 7260 averted potential ADEs annually Maviglia S, et al. “Cost-Benefit Analysis of a Hospital Pharmacy Bar Code Solution”. ARCH INTERN MED/VOL 167, APR 23, 2007,788-794. Downloaded from www.archinternmed.com on March 16, 2012 Barcode Medication Administration

  14. Results/Conclusions • The primary benefit was a decrease in adverse drug events from dispensing errors (517 events annually), resulting in an annual savings of $2.20million. The net benefit after 5 years was $3.49 million. • The rate at which potential ADEs result in actual ADEs (13.4%), and the average incremental cost to the hospital of preventable ADEs ($4600 in 1995 dollars) were used to translate error reduction rates to dollars saved. Because the savings from an averted ADE accrue to the hospital Barcode Medication Administration

  15. BCMA Potential ProblemsSelected Articles • Goldsein J. “Hospital bar codes not a perfect Rx”. Philadelphia Inquirer, July 1, 2008. Section: National; Inq Health Daily; Pg. A01 • Kean C. “No Surprise – Nurses Often Bypass Drug Bar-coding Safety Features”, Pharmacy Practice News, Volume 35, August 2008, p.32 • Koppel R, et al. “Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety”. J Am Med Inform Assoc. 2008;15:408–423. DOI 10.1197/jamia.M2616 • Casey M et al. “Pharmacist Staffing and the Use of Technology in Small Rural Hospitals: Implications for Medication Safety.” Upper Midwest Rural Health Research Center Working Paper. Dec 2005 • Sakowski et al. “Using a Bar-Coded Medication Administration System to Prevent Medication Errors in a Community Hospital Network.” Am J Health-Syst Pharm. 2005; 62:2619-2625 Barcode Medication Administration

  16. Goldstein (2008) • An article written for a Philadelphia newspaper covering an article by Koppel and colleagues • Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety • J Am Med Inform Assoc. 2008;15:408–423. DOI 10.1197/jamia.M2616. Barcode Medication Administration

  17. “A Bar Code is swell, but without a culture of safety, it is not nearly as valuable as everybody believes.”1 1. David B. Nash, chairman of the department of health policy at Jefferson Medical College. Quoted in: Goldsein J. “Hospital bar codes not a perfect Rx”. Philadelphia Inquirer, July 1, 2008. Section: National; Inq Health Daily; Pg. A01. Barcode Medication Administration

  18. "A lot of the time, the people who develop these systems think of them in the same way they think about stocking a Sam's Club," Koppel said in an interview yesterday, "but hospitals are very active places where serious things are happening all the time." • Goldstein also repeated two of Koppel’s eight recommendations that bear repeating: • Hospital executives must spend time actually watching how the systems are used • They must also demand that the vendors design systems for the real world of care Barcode Medication Administration

  19. Koppel (2008) • Koppel’s team spent several years observing the use of bar-code technology in five hospitals. They also analyzed half a million medication scans to examine how well such systems worked to reduce medication errors Koppel R, et al. “Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, and Threats to Patient Safety”. J Am Med Inform Assoc. 2008;15:408–423. DOI 10.1197/jamia.M2616 Barcode Medication Administration

  20. Observations/Results • The study found practical problems large and small, leading nurses to develop work-arounds that often undermined the system's safeguards. • The researchers found all kinds of improvisation occurring. Patient bar-code ID bands were taped to doorjambs, nurses' desks, scanners, drug-dispensing machines and clipboards, and were also worn as key chains on belts, among other places. • There were times when the battery on the computer or the scanner died. Or there was a wireless dead-spot in the hospital room. • "In 99 percent of the cases, it ain't the nurse, it is the system," Koppel said, "and sometimes it is easily fixed by reprogramming Barcode Medication Administration

  21. Casey Article (2005) • “Pharmacist Staffing and the Use of Technology in Small Rural Hospitals: Implications for Medication Safety.” • Purpose: • Assess the capacity of rural hospitals to implement medication safety practices and identify the factors that facilitate successful implementation • Determine what key facility and environmental factors – such as hospital size, system membership, accreditation, and degree of rurality – are related to rural hospitals’ pharmacist staffing, their use of technology, and implementation of medication safety practice • Methods: National telephone survey of a sample of 400 rural hospitals with 100 or fewer staffed beds Casey M et al. “Pharmacist Staffing and the Use of Technology in Small Rural Hospitals: Implications for Medication Safety.” Upper Midwest Rural Health Research Center Working Paper. Dec 2005. Barcode Medication Administration

  22. Results(1 of 2) • Forty-three percent of the responding hospitals have 25 or fewer staffed beds; 33 percent have between 26 and 50 beds, and 25 percent have over 50 beds • 47 percent are accredited by the Joint Commission on Accreditation of Healthcare Facilities (JCAHO). • 35% of the hospitals report having a pharmacist on site for less than 40 hours per week, including 31 hospitals (8%) where a pharmacist is on site for two hours or less per week • Seventeen percent of hospitals share a pharmacist with another hospital, and 13 percent have one or more vacant pharmacist positions Barcode Medication Administration

  23. Results(2 of 2) • Of the 387 hospitals in the survey, 77 percent use a pharmacy computer for one or more clinical purposes: to screen for potential drug interactions, to automatically screen for patient drug allergies, to identify potential adverse drug events, and to help determine appropriate medication doses. Forty-one hospitals do not have a computer in the pharmacy and an additional 48 hospitals do not use the pharmacy computer for clinical purposes • 51% of hospitals surveyed were using computer-generated medication administration record • 3% of hospitals surveyed were using bar code technology for bedside medication administration Barcode Medication Administration

  24. Use of Computer-generated Medication Administration Records and Bar Code Technology for Bedside Medication Administration (n=346) Barcode Medication Administration

  25. Use of Computer-generated Medication Administration Records and Bar Code Technology for Bedside Medication Administration (n=346) Barcode Medication Administration

  26. Conclusions • Limited on-site pharmacy coverage in many small rural hospitals limits the amount of time spent on medication safety activities • Cost is a major reason for NOT implementing specific medication safety-related technologies • Improving implementation of key medication safety practices among non-accredited hospitals will likely require a comprehensive approach that includes increasing awareness of the importance of implementing the practices, as well as targeted provision of technical assistance and financial incentives. Casey M et al. “Pharmacist Staffing and the Use of Technology in Small Rural Hospitals: Implications for Medication Safety.” Upper Midwest Rural Health Research Center Working Paper. Dec 2005. Barcode Medication Administration

  27. Sakowski et al.2005 • Purpose: To describe the effect of implementing a bar-coded medication administration system on medication administration errors in a network of community hospitals • Methods: A retrospective audit was conducted of warning and error reports generated by a Bar Code Point of Care system from six hospitals in the network (79-403 beds) Sakowski et al. “Using a Bar-Coded Medication Administration System to Prevent Medication Errors in a Community Hospital Network.” Am J Health-Syst Pharm. 2005; 62:2619-2625. Barcode Medication Administration

  28. Observations/Results (1 of 2) • BCMA issued alerts/warnings on 42% of all attempted administrations • This illustrates a real danger of users becoming desensitized to warnings • 33% of all attempted administrations required the nurse to verify something • Nurses used the override in 78% those attempts • 10.98% of those overrides resulted in either the drug administered at the wrong time, the dose differing from the written order, or a drug for which there was no order. Barcode Medication Administration

  29. Observations/Results (2 of 2) • Approximately 70% of warnings were due to an error in setup or process • Fixing setups, including administration schedules and drug units was required • 1.1% of all attempted administrations were stopped by discovery of a problem, averting medication administration errors. The top three types of errors prevented included: • Doses administered too early • System had no record of a particular medication being ordered • Attempted administration of a medication for an order that was discontinued or expired

  30. Conclusions(1 of 2) • The use of a bar-coded point of care system can prevent medication errors • BCMA systems accentuate setup and workflow issues that can result in a number of inappropriate warnings • Addressing system and workflow issues identified by BCMA reduces the number of inappropriate warnings and improves the effectiveness of the system • Hospital Medication Administration is a multidisciplinary process and errors can be caused by any entity involved, not just nurses

  31. Conclusions(2 of 2) • Recommendation: “Periodic assessments to confirm that users are adopting BPOC [BCMA] as expected (including “walk arounds” to observe the entry of orders and administration of medications), repeat training to reinforce best practices, and continuous monitoring of BPOC system-generated reports are needed to reduce the potential for system-caused errors” • Facilities must plan to dedicate resources to BCMA not only at implementation, but must also provide for continued maintenance and upkeep to assure its proper operation into the future

  32. Literature Search Summary (1 of 3) • BCMA, through its ability to detect errors, has been shown to prevent medication administration errors in large hospitals • Because of its complexity, BCMA is, itself, a source for medication administration errors • Staff using BCMA must be well trained and experienced. Training and competency must be continuously monitored for optimal benefit from BCMA • BCMA does not replace clinical judgment Barcode Medication Administration

  33. Summary (2 of 3) • Setting up and properly optimizing supporting pharmacy files for BCMA is critical to user satisfaction, proper use, and patient safety • The hospital must foster a culture of safety, of which BCMA is only a tool • Optimal use of BCMA may represent a cost (and reputation) savings through minimizing drug administration errors • BCMA is for life. Continuous maintenance and upkeep are required Barcode Medication Administration

  34. Summary (3 of 3) • BCMA requires coordination of efforts and cooperation between nursing, pharmacy, and Information Technology departments • Hospital medication administration is a complex process and must be optimized to avoid possible points of failure: • technology issues (hardware, network, software) • Personnel issues (staffing, policies and procedures) • Communication between departments Barcode Medication Administration

  35. Questions & Discussion Barcode Medication Administration

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