JHQ 154 - Using Bar-Code Point-of-Care Technology for Patient Safety

Sherry Anderson, BSN RN; Wendy Wittwer, BSN RN
Keywords: Information technology, Medication errors, Patient safety
November/December 2004

To err is human, the landmark 1999 Institute of Medicine report (Committee on Quality of Health Care in America [CQHCA], 2000), focused national attention on hospital errors and the stunning incidence of fatalities attributed to problems in the medication administration process. Exacerbating the patient safety issue is the disjointed use of hospital information technology systems and the impact of the increasing nursing shortage facing the United States. High on the list of possibilities for improving both these situations is bar-code point-of-care technology (Leape et al., 1995).

This article describes one hospital's experience in decreasing medication errors. Consideration is given to the magnitude of the medication safety issue and the effect of evolving information technology. The efficacy of bar-code point-of-care technology in preventing medication administration errors, the effect of the nursing shortage on medication error commission, and the potential to improve nurse satisfaction are described.

Evolution of the Patient Safety Movement

Though it is certainly the most well-known publication, the Institute of Medicine's (IOM) 1999 report on medical errors was not the first alarm sounded on patient safety (CQHCA, 2000). Following two widely publicized cases of fatal medication errors—those of a reporter in Boston in 1994 (CQHCA, 2000) and a newborn in Denver the following year (Smetzer & Cohen, 1998)—former President Clinton established the Quality Interagency Coordinating Task Force (QuIC; Brown, 2001). This initiative focused on error reduction and the development of large-scale knowledge bases to track common causes of error and to list error prevention methodologies (Brown). The IOM report, in addition to quantifying the incidence of fatal medication errors (7,000 deaths annually), endorsed the QuIC's recommendations, called for the implementation of information technology to reduce medical errors, and established the groundwork for ensuing patient safety legislation.

By May 2001, more than a half-dozen bills addressing patient safety had been submitted to Congress for approval (Brown), and in 2003 the U.S. Department of Health and Human Services launched new efforts to encourage and facilitate widespread use of modern information technology (USDHHS, July 1, 2003). This national trend to promote patient safety is beginning to saturate state legislatures, healthcare accreditors, healthcare purchasing consortiums, and healthcare organizations. Four organizations—the Institute for Healthcare Improvement, the Institute for Safe Medication Practices, the National Patient Safety Foundation, and the American Society of Health-System Pharmacists—have emerged as leaders in championing medication safety (see Figure 1 ).

Medication Safety Issue

The Adverse Drug Event Study, considered to be the landmark report on medication errors, monitored the medication process in multiple clinical units within two university-affiliated medical centers over a 6-month period (Leape et al., 1995). Of the more than 330 medication errors identified, the majority originated with an inaccurate physician's order (39%) or a nurse's erroneous administration of a medication at the patient's bedside (38%). What was most remarkable, however, was the error interception rate when redundant checks occurred throughout the medication use process. Up to one-half of all physician order inaccuracies were intercepted by nurses and pharmacists before the medication reached the patient. However, only 2% of all nursing administration mistakes were caught, making the administration phase of the medication use process the phase most fraught with error (Leape et al.). A study published in the fall of 2002 underscores the extent of this finding (Leape et al.).

In a multiple-site investigation conducted in two large metropolitan areas, researchers observed more than 3,200 doses of medications being administered to patients in 36 healthcare facilities (Barker, Flynn, Pepper, Bates, & Mikeal, 2002). More than 600 doses were delivered erroneously, leading to an overall medication administration error rate of 19%. When timing errors (early or late doses) were eliminated, approximately 1 in 10 doses was delivered erroneously (10%), and of these, approximately 10% potentially could have harmed the patient.

Evolving Technology and the Nursing Shortage

One of the most pressing issues influencing safe medication administration practices is the dearth of information technology supporting the medication-use process. While a major source of errors is the point at which physicians order medications, less than 85% of U.S. hospitals use computers for medication prescriptions (Kaushal & Bates, 2002). At the most vulnerable phase of the medication use process, the administration phase, only 1.5% of 500 hospitals surveyed use bar-code technology to verify the correct patient is receiving the correct drug (Pedersen, Schneider, & Scheckelhoff, 2003). The greatest potential effect of technology on medication administration is simplification of the process itself. One facility reduced its medication process from 60 to 10 steps by using automated, networked computer systems (Douglas & Larrabee, 2003).

The two major information technology advances receiving considerable attention for medication safety are computerized physician order entry (CPOE) and bar-code technology at the point of care (BPOC). CPOE, aimed at the "front end" of the medication use process, combines clinical decision software with standard physician order sets and uses data acquired through hospital interfaces to perfect a physician's order. BPOC focuses on the "vulnerable end," the patient's bedside, and provides the final safety net before a patient receives his or her medication.

Nursing Shortage and BPOC

A 2002 survey forecast a shortage of up to 800,000 registered nurses by the year 2020 (USDHHS, 2002). This shortage complicates the risk for bedside medication errors and is compounded by the scarcity of hospital information technology that would support registered nurses practicing in hospitals. Increased medication error rates are recognized as an effect of nursing staff shortages (Clark, 2003). Nurses already experiencing the effects of the increased workload will be drawn to hospitals that are doing the most to improve working conditions and support them in their jobs, particularly in the arena of patient safety (Case, Mowry, & Welebob, 2002). Utilization of technological advancements will be a major factor in these considerations.

A BPOC medication administration system combines the same bar-code technology used in grocery stores since the 1970s with sophisticated computerized decision support functionality. BPOC systems use a bedside computer, a server with interfaces to the admission-discharge-transfer and pharmacy systems, and medication administration software to cross-check bar codes printed on patient wristbands, nurse identification badges, and medication labels. Comparing the bar code on medications with the prescribed medications, the system matches the orders with the patient identification and verifies the "five rights" of medication safety (right patient, right drug, right dose, right route, at the right time). There are varying levels of sophistication among BPOC software systems; some systems offer additional clinical alerts regarding sound-alike/look-alike medications or other clinical advisories particular to a specific medication (see Figure 3 ). Following proper dosage administration, some BPOC systems produce an electronic medication administration record (eMAR), providing legal documentation of the facts of the administration (see Figure 4 ).

Bar-code point-of-care systems are emerging as one of the most important safeguards a hospital can implement relatively quickly, and they demonstrate their utility almost immediately. For example, Douglas and Larrabee (2003) described a hospital that implemented a BPOC system in 5 clinical units in 8 months and experienced the prevention of more than 2,100 medication errors in the first year of operation. The Veterans Health Administration (VHA) has implemented its internally developed BPOC system nationwide. Despite some issues indigenous to the system (Patterson, Cook, & Render, 2002), one VHA medical center has reported an 86% reduction in the medication error rate by using BPOC technology (Johnson, Tucker, Carlson, & Willette, 2002).

Other benefits inherent in a BPOC system are the bedside display of multiple single-patient diagnoses, admitting and consulting physicians, as well as drug information and allergy history. In addition to automating the medication administration record, some BPOC systems create electronic logs of nurse responses to clinical alerts or warnings. This database is useful for medication error risk factor root cause analyses (Douglas & Larrabee, 2003).

The significance of a BPOC system's ability to reduce medication errors is magnified by its position in the medication administration process. By providing the final check at the "vulnerable end," a BPOC system is the last safeguard against a potentially devastating adverse drug event. This bedside safety net not only has the potential to avert serious medication events, but also can reassure the nursing staff of the institution's commitment to patient and staff safety.

St. Marys Hospital's Experience

St. Marys Hospital Medical Center, a member of SSM Health Care, is a 440-bed acute care hospital offering a full range of inpatient and outpatient treatment and diagnostic services in primary care and nearly all specialties. Although the institution began addressing patient safety matters before the 1999 IOM report, the alarms sounded in this report led to more aggressive and effective mechanisms to ensure safety. The organization is steeped in a culture of continuous quality improvement and shared interdisciplinary accountability. St. Marys is the only hospital in the nation to have achieved both Magnet Recognition for Nursing Excellence and the Malcolm Baldrige National Quality Award. A strong and pervasive commitment to patient safety guided its journey as early adopters of BPOC technology, which has demonstrated its effectiveness in addressing both medication safety and nurse satisfaction.

Medication safety measures already implemented at St. Marys include

• computerized pharmacy system
• medication administration records generated by the pharmacy system
• decentralized pharmacists
• standard dosing times
• standard antibiotic dosing
• restricted purchase of similar-looking drug packages
• modified storage and labels for "sound-alike" medications
• standardized drip concentrations.

Despite these measures, occurrence reports still reflected minimal reduction in medication errors. When the origin and causes of these errors were examined, it was found that the majority of errors occurred in the administration phase (58.3%), followed by transcription errors (33.6%), ordering errors (4.4%), unknown causes (2.1%), distribution errors (1.2%), and documentation errors (0.4%). Because solutions that would affect the medication administration process offered the greatest opportunity for improvement, technology that touched the nurse and the patient at the bedside was needed.

In 1999, four different vendors and their respective technologies were evaluated, but an effective and efficient product available for purchase was not found. Vendors demonstrated software that ranged from essentially nonexistent ("vaporware") to two types of software in the alpha stages of development. After a site visit process, St. Marys chose to be a beta site for developing and implementing a BPOC system that incorporated the needs of clinical nurses and pharmacists. The goal of a 50% error reduction within 6 months was exceeded on the pilot unit and on each subsequent nursing unit. With gradual deployment of the BPOC system, the medication error rate fell by as much as 70% on some clinical units. Examples of specific unit results in 6 months were as follows:

• 59% decrease on orthopedic/oncology medical/surgical unit
• 20% decrease on neurological unit
• 70% decrease on medical intermediate care unit.

Although the system has not been fully implemented across all patient care areas, a 44% decrease in medication errors for the entire hospital has occurred since BPOC was implemented.

Lessons Learned

St. Marys learned several lessons and strategies for implementing BPOC. Two points are key. First, BPOC must be recognized as a system for both nursing and pharmacy. Second, vendor selection and implementation must be an interdisciplinary effort beyond the nursing, pharmacy, and information technology departments. Product consideration should include the following essential elements:

• real-time, electronic documentation
• ease of use by clinical nurses and clinical pharmacists
• decision support characteristics that extend beyond the "five rights"

  -alerts as to look-alike/sound-alike medications

  -24-hour maximum dose alert

  -triggers to include key related information such as associated blood sugars, injection sites, and reasons medications were not given
  – allergy checking
  – automated error and near miss tracking

• technology that would easily interface with other hospital systems (Web-based, compliant with the Health Level Seven (HL7; CCOW Standard)
• user friendly and expeditious log on/ off features
• customization features for different patient care areas
• cost
• vendor reliability during implementation and ongoing maintenance
• report functionality.

After vendor selection has occurred, 3–6 months of primarily pharmacy-related work can be required before the system is actually in use at the bedside. Care must be taken to find scanners that can interpret wide variation in bar-code symbology and patient identification armbands with ink that withstands water, sweat, and other body fluids. The people resources required in the beginning of implementation were underestimated, and this hindered project expansion later (Beaupain, 2003).

The other major consideration in implementing BPOC is cost. Some organizations have been able to accomplish a hospital-wide implementation, but St. Marys chose a staged implementation. Like most hospitals, the capital dollars available on an annual basis are limited. Implementation was staged across nursing units without creating an unmanageable burden on the pharmacy or information technology departments. This staging has provided time to evaluate and plan for the concerns raised by each unique culture of the nursing units and their patient populations. Gradual implementation afforded time to review the data the system collects, implement changes, and improve the education process on an ongoing basis. Grant money was received to help support pharmacy efforts to find methods to bar-code medications compounded by the pharmacy. Initially 40% of all medications were bar-coded. Now 84% of the medications are bar-coded, and strategies are in place to raise that percentage even higher. Selection criteria for pharmaceutical vendors include evaluating their ability to provide drugs and related products with bar codes.

The ability of the BPOC system to prevent and track averted errors was particularly important. Traditionally, these "near-misses" are underreported and elusive to trace (Larrabee & Brown, 2003). For example, the BPOC prevented and tracked more than 80 errors in a month's time on one 35-bed clinical unit. In St. Marys voluntary reporting process, typically zero to ten "near misses" would have been reported per month. Prior to the implementation of this system, nurses often were not aware that they were close to making a mistake. Now they have immediate feedback and the opportunity to avert errors. The volume of these "near misses" can be categorized by error type, which is particularly useful when systemic risk factors are being analyzed for potential error commission (see Figure 2 ).

Because implementing a BPOC system modifies the medication process workflow, nurses may initially experience anxiety and frustration. It was important therefore to consider nurse reaction and acceptance of this system following implementation. The satisfaction of nurses with the medication administration process was measured before BPOC was implemented and afterward. Overall, satisfaction rose from 3.4 points to 3.7 points (out of 5 possible points) within the 12 months following BPOC system installation. These results were somewhat disappointing but reassuring in that satisfaction remained fairly constant during and after such a significant change in how nurses administer and document medication administration. Of equal importance have been the positive comments from patients and family members who are aware that this system has been implemented for their safety.

Robust BPOC systems also have in-depth report functions. These systems generate accurate billing for medications from the point of administration, not from the more traditional point of distribution. This provides protection from inadvertent billing errors and unintentional Medicare fraud. Risk managers and department directors can utilize the data to identify organizational and department trends as well as individual performance concerns. The environment is nonpunitive and the information is used to identify knowledge gaps or process breakdowns. That insight provides needed information to plan education or process changes that will have the most meaningful effect on patients and the organization. Although organizational data are useful for evaluating system performance, improvements are best made when the data can also be stratified by individual patient care areas. This system provides that degree of reporting. Gaps in knowledge or processes that have been identified and that are being worked on include the following:

• inconsistency in insulin administration time with the consumption of food and the various peaks and duration of various types of insulin
• need for flexible respiratory therapy staffing to provide nebulizer treatments in a timely manner
• staff compliance with scanning bar codes
• inconsistency in pharmacy order entry practices
• inconsistency in nurse order verification practices
• medications not bar-coded by the manufacturer.

Conclusion

BPOC systems are an effective mechanism for preventing medication errors. These systems are a significant part of the future of healthcare technology and will become more visible as evidenced by the U.S. Food and Drug Administration (FDA) proposed ruling requiring bar codes on all medications (USDHHS, March 13, 2003). Developing databases reflecting systemic issues that influence medication error risk will assist clinicians and hospital executives to extend the safest care possible to each patient. At the same time, as the overall safety factor of hospitals increases, nurse satisfaction with the workplace will be key to organizational success. "Although technology systems that increase patient safety and clinical quality may not always increase nurse efficiency, they can relieve anxiety and enable nurses to provide safer, better care—which has a positive impact on job satisfaction, and potentially on nurse recruitment and retention," concludes a report addressing the advancing nursing shortage (Case et al., 2002, p. 7).

BPOC technology is an important progression in healthcare technology. It goes the furthest in addressing patient safety, reducing medication administration errors by more than 80%. Beyond patient safety, BPOC improves overall work flow of the hospital by creating information sets that identify potential process breakdowns. BPOC provides accurate information to reduce medication errors and promote patient safety and is becoming a mainstay of healthcare information technology and patient safety.

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Author's Biography
Sherry Anderson is the director of a nursing unit and serves as an internal quality improvement consultant at St. Marys Hospital Medical Center, Madison, WI. Anderson has practiced nursing for 28 years; the past 12 years have been focused on quality improvement initiatives that develop and foster shared accountability across departmental lines.

Wendy Wittwer is a project manager at St. Marys Hospital Medical Center. She has 13 years of experience as a staff nurse on a multispecialty medical/surgical unit. For the last three years, she has coordinated the implementation of a bar-code-enabled point-of-care system.

For more information on this article, contact Sherry Anderson by phone at 608/258-6741 or by e-mail at sherry_anderson@ssmhc.com.

References
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Beaupain, B. (Ed.). (2003). Case study: Barcode system cuts medication errors. Briefings on Patient Safety, 4(6), 1–4.

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Johnson, C.L., Carlson R.A., Tucker, C.L., & Willette, C. Using BCMA software to improve patient safety in Veterans Administration medical centers. Journal of Healthcare Information Management, 16(1), 46–51.

Kaushal, R., & Bates, D.W. (2002). Computerized physician order entry (CPOE) with clinical decision support (CDSSS). Retrieved July 12, 2003, from http:// www.ahcpr.gov/clinic/ptsafety/chapt6.htm

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Leape, L.L., Bates, D.W., Cullen, D.J., Cooper, J., Demonaco, H.J., Gallivan T., et al. (1995). Systems analysis of adverse drug events. Journal of the American Medical Association, 274(1), 35–43.

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Patterson, E.S., Cook, R.C.I. & Render, M.L. (2002). Improving patient safety by identifying side effects from introducing bar coding in medication administration. Journal of the American Medical Informatics Association, 9(5), 540–553.

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Objectives
Journal for Healthcare Quality is pleased to offer the opportunity to earn continuing education (CE) credit to those who read this article, take the posttest at www. nahq.org/journal/ce/ and complete the hard copy or online form. This continuing education offering, JHQ 154, will provide one contact hour to those who complete it appropriately.

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